diff --git a/.gitattributes b/.gitattributes
index d040881ee5d3f5135f1786c29d686a6c0c53882e..a332a4539f4615f98a905d1bbdaec498e90dab00 100644
--- a/.gitattributes
+++ b/.gitattributes
@@ -33,6 +33,7 @@ saved_model/**/* filter=lfs diff=lfs merge=lfs -text
 *.zip filter=lfs diff=lfs merge=lfs -text
 *.zst filter=lfs diff=lfs merge=lfs -text
 *tfevents* filter=lfs diff=lfs merge=lfs -text
-*.pdf filter=lfs diff=lfs merge=lfs -text
+*.onnx.data filter=lfs diff=lfs merge=lfs -text
 *.docx filter=lfs diff=lfs merge=lfs -text
 *.xlsx filter=lfs diff=lfs merge=lfs -text
+*.pdf filter=lfs diff=lfs merge=lfs -text
diff --git a/.gitignore b/.gitignore
new file mode 100644
index 0000000000000000000000000000000000000000..fafd5d86e9958b5eff671f039c61ed36ea73611b
--- /dev/null
+++ b/.gitignore
@@ -0,0 +1,3 @@
+__pycache__/
+*.py[cod]
+*.pyc
diff --git a/Dockerfile b/Dockerfile
new file mode 100644
index 0000000000000000000000000000000000000000..a804dfdf7d81ba9a3f5d9941d2c9d86363dc011c
--- /dev/null
+++ b/Dockerfile
@@ -0,0 +1,31 @@
+FROM python:3.11-slim
+
+WORKDIR /app
+
+# System dependencies
+RUN apt-get update && apt-get install -y --no-install-recommends \
+    build-essential \
+    && rm -rf /var/lib/apt/lists/*
+
+# Install only serving dependencies (no torch needed — ONNX Runtime only)
+COPY requirements-serve.txt .
+RUN pip install --no-cache-dir -r requirements-serve.txt
+
+# Copy application code
+COPY service/ service/
+COPY decision/ decision/
+COPY streaming_intent/ streaming_intent/
+COPY config/ config/
+COPY list/ list/
+COPY artifacts/onnx_int8/ artifacts/onnx_int8/
+COPY artifacts/config/ artifacts/config/
+
+# HF Spaces expects port 7860
+ENV PORT=7860
+ENV PYTHONUNBUFFERED=1
+ENV REQUIRE_AUTH=false
+ENV DISABLE_DOCS=false
+
+EXPOSE 7860
+
+CMD ["uvicorn", "service.app:app", "--host", "0.0.0.0", "--port", "7860"]
diff --git a/README.md b/README.md
index ac941dd2bb5b12fae28e19990bc5f83ae655fc13..bf2b58c135b19761357177be1f410a4372f3accf 100644
--- a/README.md
+++ b/README.md
@@ -1,11 +1,32 @@
 ---
-title: DCE
-emoji: 🏆
-colorFrom: indigo
+title: Medical Intent Escalation
+emoji: 🏥
+colorFrom: blue
 colorTo: red
 sdk: docker
 pinned: false
-short_description: Medical Intent Escalation
+license: mit
+app_port: 7860
 ---
 
-Check out the configuration reference at https://huggingface.co/docs/hub/spaces-config-reference
+# Medical Intent Escalation
+
+Real-time clinical intent classification and safety escalation API powered by DriveHealthBERT.
+
+## Endpoints
+
+- **POST /predict** — Classify medical intent from text
+- **POST /predict/clinical** — Full clinical risk assessment (R0–R3)
+- **POST /conversation/start** — Start a clinical conversation session
+- **POST /conversation/turn** — Process a patient turn
+- **POST /stream/chunk** — Process streaming STT chunks with SPRT decisions
+- **GET /health** — Health check
+- **GET /docs** — Interactive Swagger UI
+
+## Quick Test
+
+```bash
+curl -X POST "https://YOUR-SPACE.hf.space/predict" \
+  -H "Content-Type: application/json" \
+  -d '{"text": "I have been having chest pain"}'
+```
diff --git a/artifacts/config/decision_policy.json b/artifacts/config/decision_policy.json
new file mode 100644
index 0000000000000000000000000000000000000000..a4f0ad2536ea9264e7e5a2372fe9ed771dcb7c4e
--- /dev/null
+++ b/artifacts/config/decision_policy.json
@@ -0,0 +1,71 @@
+{
+  "version": "2.0.0",
+  "created_at": "2026-03-06T04:20:52.670734+00:00",
+  "escalation_policy": {
+    "escalation_label": "ESCALATION",
+    "escalation_threshold": 0.95,
+    "description": "If P(ESCALATION) >= 0.950, escalate regardless of argmax. This prioritizes recall for safety-critical escalation detection."
+  },
+  "confidence_policy": {
+    "min_confidence": 0.3,
+    "fallback_label": "OTHER",
+    "description": "If max probability < 0.3, route to OTHER for review."
+  },
+  "calibration_metrics": {
+    "threshold": 0.95,
+    "recall": 0.9696969696969697,
+    "precision": 0.898876404494382,
+    "fpr": 0.016498625114573784,
+    "tp": 160,
+    "fp": 18,
+    "tn": 1073,
+    "fn": 5,
+    "recall_ci": {
+      "point_estimate": 0.9702812759764813,
+      "ci_lower": 0.9433872701218056,
+      "ci_upper": 0.9938281072483526,
+      "confidence_level": 0.95
+    },
+    "precision_ci": {
+      "point_estimate": 0.9000275789258342,
+      "ci_lower": 0.8563822440343247,
+      "ci_upper": 0.9408681214421253,
+      "confidence_level": 0.95
+    },
+    "fpr_ci": {
+      "point_estimate": 0.016454061300607874,
+      "ci_lower": 0.009250480061420503,
+      "ci_upper": 0.02428254680618841,
+      "confidence_level": 0.95
+    }
+  },
+  "decision_logic": [
+    "1. If P(ESCALATION) >= 0.950 \u2192 ESCALATE",
+    "2. Else if max(P) < 0.3 \u2192 route to OTHER",
+    "3. Else \u2192 return argmax label"
+  ],
+  "drift_monitoring": {
+    "enabled": true,
+    "baseline_metrics": {
+      "recall": 0.9696969696969697,
+      "fpr": 0.016498625114573784,
+      "calibration_date": "2026-03-06T04:20:52.670756+00:00"
+    },
+    "alert_thresholds": {
+      "min_recall": 0.9,
+      "max_fpr": 0.3,
+      "recall_drop_from_baseline": 0.05,
+      "fpr_increase_from_baseline": 0.1
+    },
+    "revalidation_policy": {
+      "sample_size": 100,
+      "revalidation_interval_days": 30,
+      "auto_recalibrate": false
+    },
+    "safety_guardrails": {
+      "never_lower_recall_below": 0.85,
+      "never_raise_threshold_above": 0.7,
+      "require_human_approval": true
+    }
+  }
+}
\ No newline at end of file
diff --git a/artifacts/onnx_int8/config.json b/artifacts/onnx_int8/config.json
new file mode 100644
index 0000000000000000000000000000000000000000..918cc979bf4a1c33adbc41d7c815f648006fae99
--- /dev/null
+++ b/artifacts/onnx_int8/config.json
@@ -0,0 +1,44 @@
+{
+  "add_cross_attention": false,
+  "architectures": [
+    "BertForSequenceClassification"
+  ],
+  "attention_probs_dropout_prob": 0.1,
+  "bos_token_id": null,
+  "classifier_dropout": null,
+  "dtype": "float32",
+  "eos_token_id": null,
+  "hidden_act": "gelu",
+  "hidden_dropout_prob": 0.1,
+  "hidden_size": 768,
+  "id2label": {
+    "0": "ESCALATION",
+    "1": "APPOINTMENT",
+    "2": "MEDICATION",
+    "3": "SYMPTOM_CHECK",
+    "4": "GENERAL_INQUIRY",
+    "5": "BILLING"
+  },
+  "initializer_range": 0.02,
+  "intermediate_size": 3072,
+  "is_decoder": false,
+  "label2id": {
+    "APPOINTMENT": 1,
+    "BILLING": 5,
+    "ESCALATION": 0,
+    "GENERAL_INQUIRY": 4,
+    "MEDICATION": 2,
+    "SYMPTOM_CHECK": 3
+  },
+  "layer_norm_eps": 1e-12,
+  "max_position_embeddings": 512,
+  "model_type": "bert",
+  "num_attention_heads": 12,
+  "num_hidden_layers": 12,
+  "pad_token_id": 0,
+  "tie_word_embeddings": true,
+  "transformers_version": "5.0.0",
+  "type_vocab_size": 2,
+  "use_cache": false,
+  "vocab_size": 28996
+}
diff --git a/artifacts/onnx_int8/decision_policy.json b/artifacts/onnx_int8/decision_policy.json
new file mode 100644
index 0000000000000000000000000000000000000000..c0b9b8736c4211762a67e2d7548cd890356473b8
--- /dev/null
+++ b/artifacts/onnx_int8/decision_policy.json
@@ -0,0 +1,71 @@
+{
+  "version": "2.0.0",
+  "created_at": "2026-02-19T06:04:01.530506+00:00",
+  "escalation_policy": {
+    "escalation_label": "ESCALATION",
+    "escalation_threshold": 0.8069999999999998,
+    "description": "If P(ESCALATION) >= 0.807, escalate regardless of argmax. This prioritizes recall for safety-critical escalation detection."
+  },
+  "confidence_policy": {
+    "min_confidence": 0.3,
+    "fallback_label": "OTHER",
+    "description": "If max probability < 0.3, route to OTHER for review."
+  },
+  "calibration_metrics": {
+    "threshold": 0.8069999999999998,
+    "recall": 0.9515151515151515,
+    "precision": 0.9401197604790419,
+    "fpr": 0.00916590284142988,
+    "tp": 157,
+    "fp": 10,
+    "tn": 1081,
+    "fn": 8,
+    "recall_ci": {
+      "point_estimate": 0.9522554476419556,
+      "ci_lower": 0.9182282243473766,
+      "ci_upper": 0.9817073170731707,
+      "confidence_level": 0.95
+    },
+    "precision_ci": {
+      "point_estimate": 0.9408976664848623,
+      "ci_lower": 0.9015464082389816,
+      "ci_upper": 0.9719292994412722,
+      "confidence_level": 0.95
+    },
+    "fpr_ci": {
+      "point_estimate": 0.009122676909917872,
+      "ci_lower": 0.0045207956600361665,
+      "ci_upper": 0.015582034830430797,
+      "confidence_level": 0.95
+    }
+  },
+  "decision_logic": [
+    "1. If P(ESCALATION) >= 0.807 \u2192 ESCALATE",
+    "2. Else if max(P) < 0.3 \u2192 route to OTHER",
+    "3. Else \u2192 return argmax label"
+  ],
+  "drift_monitoring": {
+    "enabled": true,
+    "baseline_metrics": {
+      "recall": 0.9515151515151515,
+      "fpr": 0.00916590284142988,
+      "calibration_date": "2026-02-19T06:04:01.530524+00:00"
+    },
+    "alert_thresholds": {
+      "min_recall": 0.9,
+      "max_fpr": 0.3,
+      "recall_drop_from_baseline": 0.05,
+      "fpr_increase_from_baseline": 0.1
+    },
+    "revalidation_policy": {
+      "sample_size": 100,
+      "revalidation_interval_days": 30,
+      "auto_recalibrate": false
+    },
+    "safety_guardrails": {
+      "never_lower_recall_below": 0.85,
+      "never_raise_threshold_above": 0.7,
+      "require_human_approval": true
+    }
+  }
+}
\ No newline at end of file
diff --git a/artifacts/onnx_int8/export_metadata.json b/artifacts/onnx_int8/export_metadata.json
new file mode 100644
index 0000000000000000000000000000000000000000..30bc2826a5fa68a7d8e8ea649657d2273de7e515
--- /dev/null
+++ b/artifacts/onnx_int8/export_metadata.json
@@ -0,0 +1,9 @@
+{
+  "source_model": "artifacts\\pytorch\\latest",
+  "export_timestamp": "2026-02-09T05:34:58.146488+00:00",
+  "opset_version": 14,
+  "max_length": 64,
+  "format": "ONNX",
+  "quantization": null,
+  "provider": "CPUExecutionProvider"
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\ No newline at end of file
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new file mode 100644
index 0000000000000000000000000000000000000000..16fd4d835f2d043ebfc40024ae608c33f6119aa9
--- /dev/null
+++ b/artifacts/onnx_int8/label_mappings.json
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+{
+  "label2id": {
+    "ESCALATION": 0,
+    "APPOINTMENT": 1,
+    "MEDICATION": 2,
+    "SYMPTOM_CHECK": 3,
+    "GENERAL_INQUIRY": 4,
+    "BILLING": 5
+  },
+  "id2label": {
+    "0": "ESCALATION",
+    "1": "APPOINTMENT",
+    "2": "MEDICATION",
+    "3": "SYMPTOM_CHECK",
+    "4": "GENERAL_INQUIRY",
+    "5": "BILLING"
+  }
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\ No newline at end of file
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new file mode 100644
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@@ -0,0 +1,3 @@
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new file mode 100644
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--- /dev/null
+++ b/artifacts/onnx_int8/quantization_metadata.json
@@ -0,0 +1,12 @@
+{
+  "source_model": "artifacts\\onnx",
+  "quantization_timestamp": "2026-02-19T06:03:17.727140+00:00",
+  "quantization_type": "dynamic",
+  "weight_type": "INT8",
+  "is_quantized": true,
+  "original_size_mb": 414.67,
+  "quantized_size_mb": 413.28,
+  "compression_ratio": 1.0,
+  "provider": "CPUExecutionProvider",
+  "warning": null
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new file mode 100644
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+    "lstrip": false,
+    "normalized": false,
+    "rstrip": false,
+    "single_word": false
+  }
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+  "version": "1.0",
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+    "strategy": "LongestFirst",
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+}
\ No newline at end of file
diff --git a/artifacts/onnx_int8/tokenizer_config.json b/artifacts/onnx_int8/tokenizer_config.json
new file mode 100644
index 0000000000000000000000000000000000000000..4a3691938ce42b4c9b9ce9af3171588b50a6d09d
--- /dev/null
+++ b/artifacts/onnx_int8/tokenizer_config.json
@@ -0,0 +1,14 @@
+{
+  "backend": "tokenizers",
+  "cls_token": "[CLS]",
+  "do_lower_case": false,
+  "is_local": true,
+  "mask_token": "[MASK]",
+  "model_max_length": 1000000000000000019884624838656,
+  "pad_token": "[PAD]",
+  "sep_token": "[SEP]",
+  "strip_accents": null,
+  "tokenize_chinese_chars": true,
+  "tokenizer_class": "BertTokenizer",
+  "unk_token": "[UNK]"
+}
diff --git a/artifacts/onnx_int8/training_metadata.json b/artifacts/onnx_int8/training_metadata.json
new file mode 100644
index 0000000000000000000000000000000000000000..bf483f08a3ed338aab1fe662270992732848035f
--- /dev/null
+++ b/artifacts/onnx_int8/training_metadata.json
@@ -0,0 +1,21 @@
+{
+  "base_model": "emilyalsentzer/Bio_ClinicalBERT",
+  "max_length": 64,
+  "num_labels": 6,
+  "labels": [
+    "ESCALATION",
+    "APPOINTMENT",
+    "MEDICATION",
+    "SYMPTOM_CHECK",
+    "GENERAL_INQUIRY",
+    "BILLING"
+  ],
+  "training_config": {
+    "epochs": 8,
+    "batch_size": 16,
+    "learning_rate": 2e-05,
+    "max_length": 64
+  },
+  "timestamp": "2026-02-19T05:59:29.871942+00:00",
+  "seed": 42
+}
\ No newline at end of file
diff --git a/artifacts/onnx_int8/vocab.txt b/artifacts/onnx_int8/vocab.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fb140275c155a9c7c5a3b3e0e77a9e839594a938
--- /dev/null
+++ b/artifacts/onnx_int8/vocab.txt
@@ -0,0 +1,30522 @@
+[PAD]
+[unused0]
+[unused1]
+[unused2]
+[unused3]
+[unused4]
+[unused5]
+[unused6]
+[unused7]
+[unused8]
+[unused9]
+[unused10]
+[unused11]
+[unused12]
+[unused13]
+[unused14]
+[unused15]
+[unused16]
+[unused17]
+[unused18]
+[unused19]
+[unused20]
+[unused21]
+[unused22]
+[unused23]
+[unused24]
+[unused25]
+[unused26]
+[unused27]
+[unused28]
+[unused29]
+[unused30]
+[unused31]
+[unused32]
+[unused33]
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diff --git a/config/streaming_intent.yaml b/config/streaming_intent.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3fe080fa37daac9402c72a5274a7ce608506b8b7
--- /dev/null
+++ b/config/streaming_intent.yaml
@@ -0,0 +1,117 @@
+# Streaming Intent Router Configuration
+# HMM-style belief updating for STT chunk processing
+
+intents:
+  - ESCALATION
+  - APPOINTMENT
+  - MEDICATION
+  - SYMPTOM_CHECK
+  - BILLING
+  - GENERAL_INQUIRY
+  - OTHER
+
+# Prior distribution (initial belief state)
+prior:
+  ESCALATION: 0.05
+  APPOINTMENT: 0.15
+  MEDICATION: 0.15
+  SYMPTOM_CHECK: 0.15
+  BILLING: 0.10
+  GENERAL_INQUIRY: 0.15
+  OTHER: 0.25
+
+# Transition matrix T[i,j] = P(intent_t=j | intent_{t-1}=i)
+# Rows must sum to 1.0
+# High diagonal = "stickiness" (intent tends to persist)
+transition_matrix:
+  ESCALATION:
+    ESCALATION: 0.90
+    APPOINTMENT: 0.01
+    MEDICATION: 0.02
+    SYMPTOM_CHECK: 0.02
+    BILLING: 0.01
+    GENERAL_INQUIRY: 0.02
+    OTHER: 0.02
+  APPOINTMENT:
+    ESCALATION: 0.02
+    APPOINTMENT: 0.80
+    MEDICATION: 0.03
+    SYMPTOM_CHECK: 0.03
+    BILLING: 0.07
+    GENERAL_INQUIRY: 0.03
+    OTHER: 0.02
+  MEDICATION:
+    ESCALATION: 0.04
+    APPOINTMENT: 0.03
+    MEDICATION: 0.82
+    SYMPTOM_CHECK: 0.04
+    BILLING: 0.02
+    GENERAL_INQUIRY: 0.03
+    OTHER: 0.02
+  SYMPTOM_CHECK:
+    ESCALATION: 0.08
+    APPOINTMENT: 0.04
+    MEDICATION: 0.05
+    SYMPTOM_CHECK: 0.75
+    BILLING: 0.02
+    GENERAL_INQUIRY: 0.03
+    OTHER: 0.03
+  BILLING:
+    ESCALATION: 0.01
+    APPOINTMENT: 0.05
+    MEDICATION: 0.02
+    SYMPTOM_CHECK: 0.02
+    BILLING: 0.85
+    GENERAL_INQUIRY: 0.03
+    OTHER: 0.02
+  GENERAL_INQUIRY:
+    ESCALATION: 0.03
+    APPOINTMENT: 0.05
+    MEDICATION: 0.05
+    SYMPTOM_CHECK: 0.05
+    BILLING: 0.04
+    GENERAL_INQUIRY: 0.75
+    OTHER: 0.03
+  OTHER:
+    ESCALATION: 0.02
+    APPOINTMENT: 0.08
+    MEDICATION: 0.08
+    SYMPTOM_CHECK: 0.08
+    BILLING: 0.06
+    GENERAL_INQUIRY: 0.08
+    OTHER: 0.60
+
+# Emission model parameters
+emission:
+  alpha: 1.5          # Sharpening exponent for DriveHealthBERT probabilities
+  epsilon: 1.0e-8     # Smoothing to avoid zero probabilities
+
+# Decision thresholds
+thresholds:
+  theta_hi: 0.85      # Immediate escalation threshold
+  theta_med: 0.60     # Consecutive-steps escalation threshold
+  theta_lock: 0.70    # Commit threshold for non-escalation intents
+  K: 3                # Required consecutive steps for stability
+
+# Rolling window parameters
+window:
+  max_tokens: 64      # Default max tokens in rolling window
+  max_tokens_limit: 128  # Hard limit for max_tokens
+
+# Debounce parameters
+debounce:
+  debounce_ms: 150    # Minimum ms between updates (unless is_final)
+  min_change_chars: 3 # Minimum character change to trigger update
+
+# Model parameters
+model:
+  max_length: 48      # Max sequence length for BioClinicalBERT inference (reduced for latency)
+
+# SPRT (Sequential Probability Ratio Test) parameters
+# Used for statistically-principled escalation decisions
+sprt:
+  alpha: 0.05         # Type I error target (false escalation rate)
+  beta: 0.10          # Type II error target (missed escalation rate)
+  p0: 0.20            # H0: baseline escalation probability (non-escalation)
+  p1: 0.60            # H1: expected escalation probability (true escalation)
+  # Note: Run scripts/evaluate_sprt_streaming.py --estimate_p0_p1 to tune these
diff --git a/config/train_config.yaml b/config/train_config.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..86e454b3813a60985971febd868c5a7460e526b5
--- /dev/null
+++ b/config/train_config.yaml
@@ -0,0 +1,87 @@
+# DCE Intent BioClinicalBERT Training Configuration
+# ============================================
+# Version: 2.0.0
+# Last Updated: 2026-02-08
+
+# Model Configuration
+# Using BioClinicalBERT for medical domain accuracy
+# Reduced max_length to 48 to maintain low latency
+model:
+  base_model: "emilyalsentzer/Bio_ClinicalBERT"
+  max_length: 48  # Reduced from 64 to compensate for larger model
+  num_labels: null  # Auto-detected from dataset
+
+# Training Hyperparameters
+training:
+  learning_rate: 3.0e-5
+  epochs: 15
+  batch_size: 16
+  eval_batch_size: 32
+  warmup_ratio: 0.1
+  weight_decay: 0.01
+  gradient_accumulation_steps: 1
+  max_grad_norm: 1.0
+  
+# Optimizer
+optimizer:
+  type: "adamw"
+  betas: [0.9, 0.999]
+  eps: 1.0e-8
+
+# Scheduler
+scheduler:
+  type: "linear"  # linear warmup then linear decay
+
+# Data Paths
+data:
+  train_path: "data/examples/train.jsonl"
+  val_path: "data/examples/val.jsonl"
+  test_path: "data/examples/test.jsonl"
+  text_column: "text"
+  label_column: "label"
+
+# Output Configuration
+output:
+  base_dir: "artifacts"
+  pytorch_dir: "artifacts/pytorch"
+  save_steps: 30
+  eval_steps: 15
+  logging_steps: 15
+  save_total_limit: 2
+
+# Reproducibility
+seed: 42
+deterministic: true
+
+# Logging
+logging:
+  level: "INFO"
+  log_to_file: true
+  log_file: "artifacts/logs/training.log"
+
+# Intent Schema (Tier 1 - Required)
+intent_schema:
+  tier1:
+    - "ESCALATION"          # Urgent medical escalation
+    - "APPOINTMENT"         # Schedule/reschedule appointments
+    - "MEDICATION"          # Medication-related queries
+    - "SYMPTOM_CHECK"       # Symptom assessment
+    - "GENERAL_INQUIRY"     # General health questions
+    - "BILLING"             # Billing/insurance questions
+    - "OTHER"               # Fallback category
+  tier2:  # Optional sub-categories
+    ESCALATION:
+      - "CHEST_PAIN"
+      - "BREATHING_DIFFICULTY"
+      - "SEVERE_BLEEDING"
+      - "LOSS_OF_CONSCIOUSNESS"
+      - "OTHER_EMERGENCY"
+
+# Evaluation Metrics
+metrics:
+  primary: "macro_f1"
+  track:
+    - "accuracy"
+    - "macro_f1"
+    - "per_class_recall"
+  escalation_label: "ESCALATION"  # Label to track recall for
diff --git a/config/train_config_augmented.yaml b/config/train_config_augmented.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a36facdfb7f2a3ce4116dc078e7b29713fd21f0e
--- /dev/null
+++ b/config/train_config_augmented.yaml
@@ -0,0 +1,80 @@
+# DCE Intent BioClinicalBERT Training Configuration - Augmented Dataset
+# ======================================================================
+# Version: 2.1.0
+# Last Updated: 2026-02-13
+# Description: Training config using merged dataset with disease symptom data
+
+# Model Configuration
+model:
+  base_model: "emilyalsentzer/Bio_ClinicalBERT"
+  max_length: 48
+  num_labels: null  # Auto-detected from dataset
+
+# Training Hyperparameters
+# Slightly adjusted for larger dataset
+training:
+  learning_rate: 2.5e-5  # Slightly lower LR for larger dataset
+  epochs: 12  # Slightly fewer epochs since more data
+  batch_size: 16
+  eval_batch_size: 32
+  warmup_ratio: 0.1
+  weight_decay: 0.01
+  gradient_accumulation_steps: 1
+  max_grad_norm: 1.0
+  
+# Optimizer
+optimizer:
+  type: "adamw"
+  betas: [0.9, 0.999]
+  eps: 1.0e-8
+
+# Scheduler
+scheduler:
+  type: "linear"
+
+# Data Paths - Using merged augmented dataset
+data:
+  train_path: "data/merged/train.jsonl"
+  val_path: "data/merged/val.jsonl"
+  test_path: "data/merged/test.jsonl"
+  text_column: "text"
+  label_column: "label"
+
+# Output Configuration
+output:
+  base_dir: "artifacts"
+  pytorch_dir: "artifacts/pytorch"
+  save_steps: 50
+  eval_steps: 25
+  logging_steps: 25
+  save_total_limit: 2
+
+# Reproducibility
+seed: 42
+deterministic: true
+
+# Logging
+logging:
+  level: "INFO"
+  log_to_file: true
+  log_file: "artifacts/logs/training_augmented.log"
+
+# Intent Schema
+intent_schema:
+  tier1:
+    - "ESCALATION"
+    - "APPOINTMENT"
+    - "MEDICATION"
+    - "SYMPTOM_CHECK"
+    - "GENERAL_INQUIRY"
+    - "BILLING"
+    - "OTHER"
+
+# Evaluation Metrics
+metrics:
+  primary: "macro_f1"
+  track:
+    - "accuracy"
+    - "macro_f1"
+    - "per_class_recall"
+  escalation_label: "ESCALATION"
diff --git a/config/train_config_v2.yaml b/config/train_config_v2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b8e59ec92ddac07544b256ec10c96f2d5b31fee8
--- /dev/null
+++ b/config/train_config_v2.yaml
@@ -0,0 +1,69 @@
+# DCE Intent BioClinicalBERT Training Configuration - v2 with Hard Negatives
+# ===========================================================================
+# Version: 2.2.0
+# Description: Training with hard negative examples to reduce false positives
+
+model:
+  base_model: "emilyalsentzer/Bio_ClinicalBERT"
+  max_length: 48
+  num_labels: null
+
+training:
+  learning_rate: 2.0e-5  # Slightly lower for fine-tuning
+  epochs: 10
+  batch_size: 16
+  eval_batch_size: 32
+  warmup_ratio: 0.1
+  weight_decay: 0.01
+  gradient_accumulation_steps: 1
+  max_grad_norm: 1.0
+
+optimizer:
+  type: "adamw"
+  betas: [0.9, 0.999]
+  eps: 1.0e-8
+
+scheduler:
+  type: "linear"
+
+# Using merged_v2 with hard negatives
+data:
+  train_path: "data/merged_v2/train.jsonl"
+  val_path: "data/merged_v2/val.jsonl"
+  test_path: "data/merged_v2/test.jsonl"
+  text_column: "text"
+  label_column: "label"
+
+output:
+  base_dir: "artifacts"
+  pytorch_dir: "artifacts/pytorch"
+  save_steps: 50
+  eval_steps: 25
+  logging_steps: 25
+  save_total_limit: 2
+
+seed: 42
+deterministic: true
+
+logging:
+  level: "INFO"
+  log_to_file: true
+  log_file: "artifacts/logs/training_v2.log"
+
+intent_schema:
+  tier1:
+    - "ESCALATION"
+    - "APPOINTMENT"
+    - "MEDICATION"
+    - "SYMPTOM_CHECK"
+    - "GENERAL_INQUIRY"
+    - "BILLING"
+    - "OTHER"
+
+metrics:
+  primary: "macro_f1"
+  track:
+    - "accuracy"
+    - "macro_f1"
+    - "per_class_recall"
+  escalation_label: "ESCALATION"
diff --git a/config/train_config_v3.yaml b/config/train_config_v3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d79fa093eb0ae5e6f54299cdc992c54e704a8828
--- /dev/null
+++ b/config/train_config_v3.yaml
@@ -0,0 +1,74 @@
+# DCE Intent BioClinicalBERT Training Configuration - v3 Taxonomy Augmented
+# ===========================================================================
+# Version: 3.0.0
+# Description: Retrain with taxonomy-augmented data from 66 clinical domains
+# Changes from v2:
+#   - Merged 1,720 taxonomy-generated samples (balanced, deduplicated)
+#   - Better coverage of minority classes (GENERAL_INQUIRY, APPOINTMENT, MEDICATION)
+#   - Negation examples to reduce false positive escalations
+#   - Slightly lower LR for fine-tuning on augmented mix
+
+model:
+  base_model: "emilyalsentzer/Bio_ClinicalBERT"
+  max_length: 48
+  num_labels: null
+
+training:
+  learning_rate: 2.0e-5
+  epochs: 6
+  batch_size: 16
+  eval_batch_size: 32
+  warmup_ratio: 0.1
+  weight_decay: 0.01
+  gradient_accumulation_steps: 1
+  max_grad_norm: 1.0
+
+optimizer:
+  type: "adamw"
+  betas: [0.9, 0.999]
+  eps: 1.0e-8
+
+scheduler:
+  type: "linear"
+
+# Using merged_v3 with taxonomy augmentation
+data:
+  train_path: "data/merged_v3/train.jsonl"
+  val_path: "data/merged_v3/val.jsonl"
+  test_path: "data/merged_v3/test.jsonl"
+  text_column: "text"
+  label_column: "label"
+
+output:
+  base_dir: "artifacts"
+  pytorch_dir: "artifacts/pytorch"
+  save_steps: 200
+  eval_steps: 100
+  logging_steps: 50
+  save_total_limit: 3
+
+seed: 42
+deterministic: true
+
+logging:
+  level: "INFO"
+  log_to_file: true
+  log_file: "artifacts/logs/training_v3.log"
+
+intent_schema:
+  tier1:
+    - "ESCALATION"
+    - "APPOINTMENT"
+    - "MEDICATION"
+    - "SYMPTOM_CHECK"
+    - "GENERAL_INQUIRY"
+    - "BILLING"
+    - "OTHER"
+
+metrics:
+  primary: "macro_f1"
+  track:
+    - "accuracy"
+    - "macro_f1"
+    - "per_class_recall"
+  escalation_label: "ESCALATION"
diff --git a/config/train_config_v4.yaml b/config/train_config_v4.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..09c1da76568ff1e7b53119aac7aaa1e5932f4044
--- /dev/null
+++ b/config/train_config_v4.yaml
@@ -0,0 +1,74 @@
+# DCE Intent BioClinicalBERT Training Configuration - v4 Severity-Relabeled
+# ===========================================================================
+# Version: 4.0.0
+# Description: Retrain with severity-based relabeling, merged OTHER, R3 augmentation
+# Changes from v3:
+#   - ESCALATION/SYMPTOM_CHECK relabeled based on R3 severity rules (1,783 fixes)
+#   - OTHER merged into GENERAL_INQUIRY
+#   - 632 new R3-specific ESCALATION samples with distinct urgent phrasing
+#   - max_length increased to 64 (was 48) for edge-case multi-symptom text
+#   - Reduced escalation_weight, using focal loss for better hard-example handling
+#   - 6 labels (no more OTHER)
+
+model:
+  base_model: "emilyalsentzer/Bio_ClinicalBERT"
+  max_length: 64
+  num_labels: null
+
+training:
+  learning_rate: 2.0e-5
+  epochs: 8
+  batch_size: 16
+  eval_batch_size: 32
+  warmup_ratio: 0.1
+  weight_decay: 0.01
+  gradient_accumulation_steps: 1
+  max_grad_norm: 1.0
+
+optimizer:
+  type: "adamw"
+  betas: [0.9, 0.999]
+  eps: 1.0e-8
+
+scheduler:
+  type: "linear"
+
+data:
+  train_path: "data/merged_v4/train.jsonl"
+  val_path: "data/merged_v4/val.jsonl"
+  test_path: "data/merged_v4/test.jsonl"
+  text_column: "text"
+  label_column: "label"
+
+output:
+  base_dir: "artifacts"
+  pytorch_dir: "artifacts/pytorch"
+  save_steps: 200
+  eval_steps: 100
+  logging_steps: 50
+  save_total_limit: 3
+
+seed: 42
+deterministic: true
+
+logging:
+  level: "INFO"
+  log_to_file: true
+  log_file: "artifacts/logs/training_v4.log"
+
+intent_schema:
+  tier1:
+    - "ESCALATION"
+    - "APPOINTMENT"
+    - "MEDICATION"
+    - "SYMPTOM_CHECK"
+    - "GENERAL_INQUIRY"
+    - "BILLING"
+
+metrics:
+  primary: "macro_f1"
+  track:
+    - "accuracy"
+    - "macro_f1"
+    - "per_class_recall"
+  escalation_label: "ESCALATION"
diff --git a/config/train_config_v5.yaml b/config/train_config_v5.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..cb9e45ef0d1aa1ae98a54514e68a68be52dd55cf
--- /dev/null
+++ b/config/train_config_v5.yaml
@@ -0,0 +1,71 @@
+# DCE Intent BioClinicalBERT Training Configuration - v5 Temporal Context
+# ===========================================================================
+# Version: 5.0.0
+# Description: v4 base + 1,180 temporal/historical context samples
+# Changes from v4:
+#   - 820 past/resolved symptom samples (SYMPTOM_CHECK) - teaches past tense
+#   - 280 still-active-despite-past-framing samples (ESCALATION) - preserves recall
+#   - 80 third-party/informational samples (GENERAL_INQUIRY)
+#   - Total: 7,338 train + 1,256 val
+
+model:
+  base_model: "emilyalsentzer/Bio_ClinicalBERT"
+  max_length: 64
+  num_labels: null
+
+training:
+  learning_rate: 2.0e-5
+  epochs: 8
+  batch_size: 16
+  eval_batch_size: 32
+  warmup_ratio: 0.1
+  weight_decay: 0.01
+  gradient_accumulation_steps: 1
+  max_grad_norm: 1.0
+
+optimizer:
+  type: "adamw"
+  betas: [0.9, 0.999]
+  eps: 1.0e-8
+
+scheduler:
+  type: "linear"
+
+data:
+  train_path: "data/merged_v5/train.jsonl"
+  val_path: "data/merged_v5/val.jsonl"
+  text_column: "text"
+  label_column: "label"
+
+output:
+  base_dir: "artifacts"
+  pytorch_dir: "artifacts/pytorch"
+  save_steps: 200
+  eval_steps: 100
+  logging_steps: 50
+  save_total_limit: 3
+
+seed: 42
+deterministic: true
+
+logging:
+  level: "INFO"
+  log_to_file: true
+  log_file: "artifacts/logs/training_v5.log"
+
+intent_schema:
+  tier1:
+    - "ESCALATION"
+    - "APPOINTMENT"
+    - "MEDICATION"
+    - "SYMPTOM_CHECK"
+    - "GENERAL_INQUIRY"
+    - "BILLING"
+
+metrics:
+  primary: "macro_f1"
+  track:
+    - "accuracy"
+    - "macro_f1"
+    - "per_class_recall"
+  escalation_label: "ESCALATION"
diff --git a/config/train_config_v6.yaml b/config/train_config_v6.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6ee49a188fc8209c1a68d122579f0730bb90201c
--- /dev/null
+++ b/config/train_config_v6.yaml
@@ -0,0 +1,75 @@
+# DCE Intent BioClinicalBERT Training Configuration - v6 Temporal Edge Cases
+# ===========================================================================
+# Version: 6.0.0
+# Description: v5 base + 840 temporal edge case samples
+# Changes from v5:
+#   - 300 BUT-clause reversal samples (ESCALATION) - "felt better but now it's back"
+#   - 300 proxy/third-party urgent reports (ESCALATION) - "my mom says chest hurts"
+#   - 90 proxy non-urgent (SYMPTOM_CHECK/GENERAL_INQUIRY) - "my friend had X last year"
+#   - 80 mixed temporal active (ESCALATION) - "had X and it hasn't gone away"
+#   - 20 intermittent dangerous (ESCALATION) - "sometimes I have trouble breathing"
+#   - 25 negated symptoms (SYMPTOM_CHECK) - "I don't have chest pain"
+#   - 25 informational (GENERAL_INQUIRY) - "what causes seizures"
+#   - Total: ~8,178 train + 1,256 val
+
+model:
+  base_model: "emilyalsentzer/Bio_ClinicalBERT"
+  max_length: 64
+  num_labels: null
+
+training:
+  learning_rate: 2.0e-5
+  epochs: 8
+  batch_size: 16
+  eval_batch_size: 32
+  warmup_ratio: 0.1
+  weight_decay: 0.01
+  gradient_accumulation_steps: 1
+  max_grad_norm: 1.0
+
+optimizer:
+  type: "adamw"
+  betas: [0.9, 0.999]
+  eps: 1.0e-8
+
+scheduler:
+  type: "linear"
+
+data:
+  train_path: "data/merged_v6/train.jsonl"
+  val_path: "data/merged_v6/val.jsonl"
+  text_column: "text"
+  label_column: "label"
+
+output:
+  base_dir: "artifacts"
+  pytorch_dir: "artifacts/pytorch"
+  save_steps: 200
+  eval_steps: 100
+  logging_steps: 50
+  save_total_limit: 3
+
+seed: 42
+deterministic: true
+
+logging:
+  level: "INFO"
+  log_to_file: true
+  log_file: "artifacts/logs/training_v6.log"
+
+intent_schema:
+  tier1:
+    - "ESCALATION"
+    - "APPOINTMENT"
+    - "MEDICATION"
+    - "SYMPTOM_CHECK"
+    - "GENERAL_INQUIRY"
+    - "BILLING"
+
+metrics:
+  primary: "macro_f1"
+  track:
+    - "accuracy"
+    - "macro_f1"
+    - "per_class_recall"
+  escalation_label: "ESCALATION"
diff --git a/decision/context/fhir_mappings.yaml b/decision/context/fhir_mappings.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..95b6fa446eb5d6db93754a3721d248023a74ee46
--- /dev/null
+++ b/decision/context/fhir_mappings.yaml
@@ -0,0 +1,61 @@
+# FHIR Resource Mappings for Patient Context
+#
+# Maps FHIR resources to PatientContext fields, organized by wedge.
+# Used by PatientContextBuilder to fetch only what's needed (minimum necessary).
+
+# Which FHIR resources to fetch per wedge (minimum necessary principle)
+wedge_resources:
+  post_discharge_engagement:
+    - Patient
+    - Condition
+    - MedicationRequest
+    - Observation  # labs + vitals
+    - AllergyIntolerance
+    - Encounter
+    - DocumentReference  # discharge summary
+    - Appointment
+  pre_op_optimization:
+    - Patient
+    - Condition
+    - MedicationRequest
+    - AllergyIntolerance
+    - ServiceRequest  # scheduled procedures
+    - Appointment
+  annual_wellness_visit:
+    - Patient
+    - Condition
+    - MedicationRequest
+    - Observation
+    - Immunization
+    - AllergyIntolerance
+  gap_closure:
+    - Patient
+    - Condition
+    - Immunization
+    - Observation  # screening results
+  health_risk_assessment:
+    - Patient
+    - Condition
+    - MedicationRequest
+    - Observation  # labs + screenings
+    - AllergyIntolerance
+
+# Default lookback periods per resource type
+lookback_days:
+  Observation_laboratory: 90
+  Observation_vital_signs: 30
+  MedicationRequest: 365
+  Condition: null  # all active, no date filter
+  Encounter: 365
+  Immunization: 730
+  Appointment: 90  # upcoming only
+
+# Freshness thresholds (hours) for staleness detection
+freshness_thresholds:
+  MedicationRequest: 24
+  Condition: 168  # 7 days
+  Observation_laboratory: 48
+  Observation_vital_signs: 24
+  AllergyIntolerance: 720  # 30 days
+  Immunization: 720
+  Appointment: 12
diff --git a/decision/engine/__init__.py b/decision/engine/__init__.py
new file mode 100644
index 0000000000000000000000000000000000000000..2fdb98641489b3e5a4022f00bdb65fee56c95584
--- /dev/null
+++ b/decision/engine/__init__.py
@@ -0,0 +1,55 @@
+"""
+Decision Engine for DCE Intent Classification.
+
+Phase 1: Safety Trifecta
+  - Taxonomy trigger matching (phrase, regex, partial, negation)
+  - Domain nomination (DriveHealthBERT + triggers → ranked domains)
+  - Risk classification (R0/R1/R2/R3)
+
+Phase 2: Conversation Engine
+  - Flow execution (state machine, slot tracking)
+  - Streaming flow integration
+
+Phase 3: Clinical Intelligence
+  - FHIR context-aware risk rules
+  - Multi-tenant configuration
+  - Journey orchestration
+"""
+
+from decision.engine.models import (
+    ConfidenceTier,
+    RiskClass,
+    TriggerMatch,
+    DomainNomination,
+    RiskAssessment,
+    NegationResult,
+)
+from decision.engine.trigger_engine import TaxonomyTriggerEngine
+from decision.engine.domain_nomination import DomainNominator
+from decision.engine.risk_classifier import RiskClassifier
+from decision.engine.config_loader import DecisionConfigLoader
+from decision.engine.flow_engine import FlowEngine, FlowResolver, TurnResult
+from decision.engine.fhir_context import PatientContext, PatientContextBuilder
+from decision.engine.tenant_manager import TenantManager, TenantConfig
+from decision.engine.journey_orchestrator import JourneyOrchestrator
+
+__all__ = [
+    "ConfidenceTier",
+    "RiskClass",
+    "TriggerMatch",
+    "DomainNomination",
+    "RiskAssessment",
+    "NegationResult",
+    "TaxonomyTriggerEngine",
+    "DomainNominator",
+    "RiskClassifier",
+    "DecisionConfigLoader",
+    "FlowEngine",
+    "FlowResolver",
+    "TurnResult",
+    "PatientContext",
+    "PatientContextBuilder",
+    "TenantManager",
+    "TenantConfig",
+    "JourneyOrchestrator",
+]
diff --git a/decision/engine/config_loader.py b/decision/engine/config_loader.py
new file mode 100644
index 0000000000000000000000000000000000000000..13c45ec8355852709b4c1031877a982f26eaf3a4
--- /dev/null
+++ b/decision/engine/config_loader.py
@@ -0,0 +1,472 @@
+"""
+Configuration loader for the Decision Engine.
+
+Loads and validates all YAML configuration from the decision/ folder:
+  - global/global_rules.yaml
+  - taxonomy/*/triggers.yaml, rules.yaml, flows/*.yaml
+  - primitives/*.yaml
+  - orchestrator/*.yaml
+  - context/fhir_mappings.yaml
+  - tenants/*/tenant.yaml
+  - journeys/*.yaml
+"""
+
+from __future__ import annotations
+
+import logging
+import os
+import re
+from pathlib import Path
+from typing import Any, Dict, List, Optional, Set
+
+import yaml
+
+logger = logging.getLogger("decision.config_loader")
+
+
+class DecisionConfigLoader:
+    """Loads and caches all decision engine configuration from YAML files."""
+
+    def __init__(self, decision_dir: str | Path):
+        self.decision_dir = Path(decision_dir)
+        if not self.decision_dir.is_dir():
+            raise FileNotFoundError(
+                f"Decision config directory not found: {self.decision_dir}"
+            )
+
+        # Loaded config caches
+        self._global_rules: Optional[Dict[str, Any]] = None
+        self._taxonomy_triggers: Optional[Dict[str, Dict[str, Any]]] = None
+        self._taxonomy_rules: Optional[Dict[str, Dict[str, Any]]] = None
+        self._taxonomy_flows: Optional[Dict[str, Dict[str, Dict[str, Any]]]] = None
+        self._primitives: Optional[Dict[str, Dict[str, Any]]] = None
+        self._orchestrator: Optional[Dict[str, Dict[str, Any]]] = None
+        self._fhir_mappings: Optional[Dict[str, Any]] = None
+        self._tenants: Optional[Dict[str, Dict[str, Any]]] = None
+        self._journeys: Optional[Dict[str, Dict[str, Any]]] = None
+
+    # ------------------------------------------------------------------
+    # Public API
+    # ------------------------------------------------------------------
+
+    def load_all(self) -> None:
+        """Load all configuration files. Call once at startup."""
+        logger.info("Loading decision engine configuration from %s", self.decision_dir)
+        self._load_global_rules()
+        self._load_taxonomy()
+        self._load_primitives()
+        self._load_orchestrator()
+        self._load_fhir_mappings()
+        self._load_tenants()
+        self._load_journeys()
+        self._validate()
+        logger.info(
+            "Decision config loaded: %d domains, %d primitives, %d tenants, %d journeys",
+            len(self._taxonomy_triggers or {}),
+            len(self._primitives or {}),
+            len(self._tenants or {}),
+            len(self._journeys or {}),
+        )
+
+    @property
+    def global_rules(self) -> Dict[str, Any]:
+        if self._global_rules is None:
+            self._load_global_rules()
+        return self._global_rules
+
+    @property
+    def taxonomy_triggers(self) -> Dict[str, Dict[str, Any]]:
+        """domain_name -> triggers.yaml content"""
+        if self._taxonomy_triggers is None:
+            self._load_taxonomy()
+        return self._taxonomy_triggers
+
+    @property
+    def taxonomy_rules(self) -> Dict[str, Dict[str, Any]]:
+        """domain_name -> rules.yaml content"""
+        if self._taxonomy_rules is None:
+            self._load_taxonomy()
+        return self._taxonomy_rules
+
+    @property
+    def taxonomy_flows(self) -> Dict[str, Dict[str, Dict[str, Any]]]:
+        """domain_name -> {flow_id -> flow.yaml content}"""
+        if self._taxonomy_flows is None:
+            self._load_taxonomy()
+        return self._taxonomy_flows
+
+    @property
+    def primitives(self) -> Dict[str, Dict[str, Any]]:
+        if self._primitives is None:
+            self._load_primitives()
+        return self._primitives
+
+    @property
+    def orchestrator(self) -> Dict[str, Dict[str, Any]]:
+        if self._orchestrator is None:
+            self._load_orchestrator()
+        return self._orchestrator
+
+    @property
+    def fhir_mappings(self) -> Dict[str, Any]:
+        if self._fhir_mappings is None:
+            self._load_fhir_mappings()
+        return self._fhir_mappings
+
+    @property
+    def tenants(self) -> Dict[str, Dict[str, Any]]:
+        if self._tenants is None:
+            self._load_tenants()
+        return self._tenants
+
+    @property
+    def journeys(self) -> Dict[str, Dict[str, Any]]:
+        if self._journeys is None:
+            self._load_journeys()
+        return self._journeys
+
+    # ------------------------------------------------------------------
+    # Derived accessors
+    # ------------------------------------------------------------------
+
+    @property
+    def safety_precedence(self) -> List[str]:
+        """Ordered list of domains by clinical acuity (highest first)."""
+        return self.global_rules.get("safety_precedence", [])
+
+    @property
+    def hard_escalate_domains(self) -> Set[str]:
+        """Domains that always escalate regardless of confidence.
+
+        Includes both explicitly listed domains from global_rules AND
+        any taxonomy domain whose rules.yaml declares target_risk_class: R3.
+        """
+        explicit = set(self.global_rules.get("hard_escalate_domains", []))
+        # Auto-include every domain with target_risk_class R3
+        for domain_name, rules in (self._taxonomy_rules or {}).items():
+            if rules.get("target_risk_class") == "R3":
+                explicit.add(domain_name)
+        return explicit
+
+    @property
+    def risk_escalation_rules(self) -> List[Dict[str, Any]]:
+        """Risk escalation rule definitions from global_rules."""
+        return self.global_rules.get("risk_escalation_rules", [])
+
+    @property
+    def domain_suppression_rules(self) -> List[Dict[str, Any]]:
+        """Domain suppression rules from global_rules."""
+        return self.global_rules.get("domain_suppression", [])
+
+    @property
+    def risk_class_descriptions(self) -> Dict[str, str]:
+        """R0/R1/R2/R3 descriptions."""
+        return self.global_rules.get("risk_classes", {})
+
+    @property
+    def domain_names(self) -> List[str]:
+        """All known domain names from taxonomy."""
+        return sorted(self.taxonomy_triggers.keys())
+
+    def get_tenant(self, tenant_id: str) -> Optional[Dict[str, Any]]:
+        """Get tenant config by ID."""
+        return self.tenants.get(tenant_id)
+
+    def get_domain_priority(self, domain: str) -> int:
+        """Get priority for a domain (higher = more urgent). Default 0."""
+        triggers = self.taxonomy_triggers.get(domain, {})
+        return triggers.get("priority", 0)
+
+    def get_domain_target_risk(self, domain: str) -> Optional[str]:
+        """Get default target risk class for a domain from rules.yaml."""
+        rules = self.taxonomy_rules.get(domain, {})
+        return rules.get("target_risk_class")
+
+    def get_domain_decision_rules(self, domain: str) -> List[Dict[str, Any]]:
+        """Get decision rules for a domain."""
+        rules = self.taxonomy_rules.get(domain, {})
+        return rules.get("decision_rules", [])
+
+    # ------------------------------------------------------------------
+    # Internal loaders
+    # ------------------------------------------------------------------
+
+    def _safe_load_yaml(self, path: Path) -> Dict[str, Any]:
+        """Load a YAML file safely, returning empty dict on error."""
+        try:
+            with open(path, "r", encoding="utf-8") as f:
+                data = yaml.safe_load(f)
+                return data if isinstance(data, dict) else {}
+        except Exception as e:
+            logger.warning("Failed to load YAML %s: %s", path, e)
+            return {}
+
+    def _load_global_rules(self) -> None:
+        path = self.decision_dir / "global" / "global_rules.yaml"
+        self._global_rules = self._safe_load_yaml(path)
+        if not self._global_rules:
+            logger.error("CRITICAL: global_rules.yaml is empty or missing at %s", path)
+
+    def _load_taxonomy(self) -> None:
+        self._taxonomy_triggers = {}
+        self._taxonomy_rules = {}
+        self._taxonomy_flows = {}
+
+        taxonomy_dir = self.decision_dir / "taxonomy"
+        if not taxonomy_dir.is_dir():
+            logger.warning("Taxonomy directory not found: %s", taxonomy_dir)
+            return
+
+        for domain_dir in sorted(taxonomy_dir.iterdir()):
+            if not domain_dir.is_dir():
+                continue
+            domain_name = domain_dir.name
+
+            # Load triggers.yaml
+            triggers_path = domain_dir / "triggers.yaml"
+            if triggers_path.is_file():
+                triggers = self._safe_load_yaml(triggers_path)
+                if triggers:
+                    self._taxonomy_triggers[domain_name] = triggers
+                    # Pre-compile regex patterns for performance
+                    self._compile_trigger_regex(domain_name, triggers)
+
+            # Load rules.yaml
+            rules_path = domain_dir / "rules.yaml"
+            if rules_path.is_file():
+                rules = self._safe_load_yaml(rules_path)
+                if rules:
+                    self._taxonomy_rules[domain_name] = rules
+
+            # Load flows/*.yaml
+            flows_dir = domain_dir / "flows"
+            if flows_dir.is_dir():
+                domain_flows = {}
+                for flow_file in sorted(flows_dir.iterdir()):
+                    if flow_file.suffix in (".yaml", ".yml"):
+                        flow_data = self._safe_load_yaml(flow_file)
+                        if flow_data:
+                            flow_id = flow_data.get("flow_id", flow_file.stem)
+                            domain_flows[flow_id] = flow_data
+                if domain_flows:
+                    self._taxonomy_flows[domain_name] = domain_flows
+
+    def _compile_trigger_regex(
+        self, domain_name: str, triggers: Dict[str, Any]
+    ) -> None:
+        """Pre-compile regex patterns in trigger definitions for performance."""
+        lexical = triggers.get("lexical_signals", {})
+        for tier_name in ("high", "medium", "low"):
+            tier = lexical.get(tier_name, {})
+            raw_patterns = tier.get("regex", [])
+            compiled = []
+            for pattern in raw_patterns:
+                try:
+                    compiled.append(re.compile(pattern, re.IGNORECASE))
+                except re.error as e:
+                    logger.warning(
+                        "Invalid regex in %s/%s: %r → %s",
+                        domain_name,
+                        tier_name,
+                        pattern,
+                        e,
+                    )
+            tier["_compiled_regex"] = compiled
+
+        # Compile negation patterns
+        negation = triggers.get("negation_handling", {})
+        neg_patterns = negation.get("patterns", [])
+        negation["_compiled_patterns"] = [
+            p.lower() for p in neg_patterns
+        ]
+
+    def load_additional_taxonomy(self, taxonomy_dir: str | Path) -> int:
+        """
+        Load additional taxonomy domains from a secondary directory.
+        
+        Only loads domains that are NOT already present in the primary taxonomy.
+        Returns the number of new domains added.
+        """
+        taxonomy_dir = Path(taxonomy_dir)
+        if not taxonomy_dir.is_dir():
+            logger.warning("Additional taxonomy directory not found: %s", taxonomy_dir)
+            return 0
+
+        if self._taxonomy_triggers is None:
+            self._taxonomy_triggers = {}
+        if self._taxonomy_rules is None:
+            self._taxonomy_rules = {}
+        if self._taxonomy_flows is None:
+            self._taxonomy_flows = {}
+
+        added = 0
+        for domain_dir in sorted(taxonomy_dir.iterdir()):
+            if not domain_dir.is_dir():
+                continue
+            domain_name = domain_dir.name
+
+            # Skip domains already loaded from primary taxonomy
+            if domain_name in self._taxonomy_triggers:
+                continue
+
+            # Load triggers.yaml
+            triggers_path = domain_dir / "triggers.yaml"
+            if triggers_path.is_file():
+                triggers = self._safe_load_yaml(triggers_path)
+                if triggers:
+                    self._taxonomy_triggers[domain_name] = triggers
+                    self._compile_trigger_regex(domain_name, triggers)
+
+            # Load rules.yaml
+            rules_path = domain_dir / "rules.yaml"
+            if rules_path.is_file():
+                rules = self._safe_load_yaml(rules_path)
+                if rules:
+                    self._taxonomy_rules[domain_name] = rules
+
+            # Load flows/*.yaml
+            flows_dir = domain_dir / "flows"
+            if flows_dir.is_dir():
+                domain_flows = {}
+                for flow_file in sorted(flows_dir.iterdir()):
+                    if flow_file.suffix in (".yaml", ".yml"):
+                        flow_data = self._safe_load_yaml(flow_file)
+                        if flow_data:
+                            flow_id = flow_data.get("flow_id", flow_file.stem)
+                            domain_flows[flow_id] = flow_data
+                if domain_flows:
+                    self._taxonomy_flows[domain_name] = domain_flows
+
+            added += 1
+
+        if added:
+            logger.info(
+                "Loaded %d additional taxonomy domains from %s (total: %d)",
+                added, taxonomy_dir, len(self._taxonomy_triggers),
+            )
+        return added
+
+    def _load_primitives(self) -> None:
+        self._primitives = {}
+        prim_dir = self.decision_dir / "primitives"
+        if not prim_dir.is_dir():
+            return
+        for f in sorted(prim_dir.iterdir()):
+            if f.suffix in (".yaml", ".yml"):
+                data = self._safe_load_yaml(f)
+                if data:
+                    flow_id = data.get("flow_id", f.stem)
+                    self._primitives[flow_id] = data
+
+    def _load_orchestrator(self) -> None:
+        self._orchestrator = {}
+        orch_dir = self.decision_dir / "orchestrator"
+        if not orch_dir.is_dir():
+            return
+        for f in sorted(orch_dir.iterdir()):
+            if f.suffix in (".yaml", ".yml"):
+                data = self._safe_load_yaml(f)
+                if data:
+                    self._orchestrator[f.stem] = data
+
+    def _load_fhir_mappings(self) -> None:
+        path = self.decision_dir / "context" / "fhir_mappings.yaml"
+        self._fhir_mappings = self._safe_load_yaml(path) if path.is_file() else {}
+
+    def _load_tenants(self) -> None:
+        self._tenants = {}
+        tenants_dir = self.decision_dir / "tenants"
+        if not tenants_dir.is_dir():
+            return
+        for tenant_dir in sorted(tenants_dir.iterdir()):
+            if not tenant_dir.is_dir():
+                continue
+            tenant_path = tenant_dir / "tenant.yaml"
+            if tenant_path.is_file():
+                data = self._safe_load_yaml(tenant_path)
+                if data:
+                    tid = data.get("tenant_id", tenant_dir.name)
+                    self._tenants[tid] = data
+
+    def _load_journeys(self) -> None:
+        self._journeys = {}
+        journeys_dir = self.decision_dir / "journeys"
+        if not journeys_dir.is_dir():
+            return
+        for f in sorted(journeys_dir.iterdir()):
+            if f.suffix in (".yaml", ".yml"):
+                data = self._safe_load_yaml(f)
+                if data:
+                    wt = data.get("wedge_type", f.stem)
+                    self._journeys[wt] = data
+
+    # ------------------------------------------------------------------
+    # Validation
+    # ------------------------------------------------------------------
+
+    def _validate(self) -> None:
+        """Run basic validation checks on loaded configuration."""
+        errors = []
+
+        # Check global rules has required keys
+        required_global_keys = [
+            "safety_precedence",
+            "risk_classes",
+            "risk_escalation_rules",
+            "hard_escalate_domains",
+        ]
+        for key in required_global_keys:
+            if key not in self.global_rules:
+                errors.append(f"global_rules.yaml missing required key: {key}")
+
+        # Check every domain in safety_precedence has triggers
+        for domain in self.safety_precedence:
+            if domain not in self.taxonomy_triggers:
+                errors.append(
+                    f"safety_precedence domain '{domain}' has no triggers.yaml"
+                )
+
+        # Check hard_escalate domains exist
+        for domain in self.hard_escalate_domains:
+            if domain not in self.taxonomy_triggers:
+                errors.append(
+                    f"hard_escalate domain '{domain}' has no triggers.yaml"
+                )
+
+        # Check risk escalation rules reference valid domains
+        for rule in self.risk_escalation_rules:
+            rule_domain = rule.get("if", {}).get("domain")
+            if rule_domain and rule_domain not in self.taxonomy_triggers:
+                errors.append(
+                    f"risk rule '{rule.get('id')}' references unknown domain "
+                    f"'{rule_domain}'"
+                )
+
+        # Check tenant wedge references
+        for tid, tenant in self.tenants.items():
+            for wedge in tenant.get("enabled_wedges", []):
+                # Map short names to journey keys
+                if wedge not in self.journeys:
+                    # Try mapping common abbreviations
+                    mapping = {
+                        "pde": "pde",
+                        "pre_op": "pre_op",
+                        "awv": "awv",
+                        "gap_closure": "gap_closure",
+                        "hra": "hra",
+                    }
+                    if wedge not in mapping:
+                        logger.debug(
+                            "Tenant '%s' references wedge '%s' not in journeys",
+                            tid,
+                            wedge,
+                        )
+
+        if errors:
+            for err in errors:
+                logger.warning("Config validation: %s", err)
+            logger.warning(
+                "Decision config has %d validation warning(s)", len(errors)
+            )
+        else:
+            logger.info("Decision config validation passed")
diff --git a/decision/engine/domain_nomination.py b/decision/engine/domain_nomination.py
new file mode 100644
index 0000000000000000000000000000000000000000..6dde1ad6ab020d9bce8100dacfa0653262b60f65
--- /dev/null
+++ b/decision/engine/domain_nomination.py
@@ -0,0 +1,326 @@
+"""
+Domain Nomination Layer.
+
+Combines DriveHealthBERT ML output with taxonomy trigger matches to produce
+a ranked list of clinical domain nominations.
+
+The nomination algorithm:
+  1. Run taxonomy triggers against the text → domain match results
+  2. Receive DriveHealthBERT label + probabilities
+  3. Fuse signals: ML confidence reinforces or weakens trigger confidence
+  4. Apply hard-escalate rules (suicidal_ideation, homicidal_ideation)
+  5. Rank by: (a) effective_confidence tier, (b) domain priority, (c) ML prob
+  6. Select recommended_flow from domain rules based on confidence tier
+  7. Return sorted list of DomainNomination objects
+
+Safety invariants:
+  - Hard-escalate domains ALWAYS nominate at HIGH confidence
+  - Negated domains are included but marked (caller decides)
+  - If ML says ESCALATION but no triggers match, still nominate with
+    a generic "unclassified_escalation" domain
+  - If triggers match a safety domain but ML says non-escalation,
+    the trigger OVERRIDES the ML (fail-open)
+"""
+
+from __future__ import annotations
+
+import logging
+from typing import Any, Dict, List, Optional, Set, Tuple
+
+from decision.engine.config_loader import DecisionConfigLoader
+from decision.engine.models import (
+    ConfidenceTier,
+    DomainNomination,
+    NegationResult,
+    RiskClass,
+    TriggerMatch,
+)
+from decision.engine.trigger_engine import DomainMatchResult, TaxonomyTriggerEngine
+
+logger = logging.getLogger("decision.domain_nomination")
+
+# DriveHealthBERT label → taxonomy domain mapping hints
+# Used when ML label alone doesn't resolve to a specific domain
+_ML_LABEL_DOMAIN_HINTS: Dict[str, List[str]] = {
+    "SCHEDULING": ["scheduling", "scheduling_barrier", "missed_followup"],
+    "MEDICATION": ["medication", "medication_nonadherence"],
+    "SYMPTOM_CHECK": [],  # Too broad — rely on triggers
+    "BILLING": [],         # No taxonomy domain for billing yet
+    "GENERAL": [],
+    "ESCALATION": [],      # Rely on triggers to determine which domain
+}
+
+
+class DomainNominator:
+    """
+    Produces ranked domain nominations from ML + lexical signals.
+
+    Usage:
+        nominator = DomainNominator(config, trigger_engine)
+        nominations = nominator.nominate(
+            text="my chest is killing me",
+            ml_label="ESCALATION",
+            ml_probabilities={"ESCALATION": 0.92, ...},
+        )
+    """
+
+    def __init__(
+        self,
+        config: DecisionConfigLoader,
+        trigger_engine: TaxonomyTriggerEngine,
+    ):
+        self._config = config
+        self._trigger_engine = trigger_engine
+        self._hard_escalate: Set[str] = config.hard_escalate_domains
+        self._safety_precedence: List[str] = config.safety_precedence
+
+    def nominate(
+        self,
+        text: str,
+        ml_label: Optional[str] = None,
+        ml_probabilities: Optional[Dict[str, float]] = None,
+    ) -> List[DomainNomination]:
+        """
+        Produce ranked domain nominations for the given text.
+
+        Args:
+            text: Patient utterance (original, NOT context-prepended)
+            ml_label: DriveHealthBERT predicted label (e.g., "ESCALATION")
+            ml_probabilities: Full probability distribution from DriveHealthBERT
+
+        Returns:
+            List of DomainNomination sorted by:
+              1. Effective confidence tier (HIGH > MEDIUM > LOW)
+              2. Domain priority (higher = more urgent)
+              3. ML probability (if available)
+        """
+        ml_confidence = None
+        if ml_probabilities and ml_label:
+            ml_confidence = ml_probabilities.get(ml_label, 0.0)
+
+        # Step 1: Run taxonomy triggers
+        trigger_results = self._trigger_engine.match_all(text)
+
+        # Step 2: Build nominations from trigger results
+        nominations: List[DomainNomination] = []
+
+        for domain_name, match_result in trigger_results.items():
+            nomination = self._build_nomination(
+                domain_name=domain_name,
+                match_result=match_result,
+                ml_label=ml_label,
+                ml_confidence=ml_confidence,
+            )
+            nominations.append(nomination)
+
+        # Step 3: Handle hard-escalate domains
+        #   If any hard-escalate domain matched (even at LOW), force HIGH
+        for nom in nominations:
+            if nom.domain in self._hard_escalate and not nom.is_negated:
+                nominations = [
+                    self._force_high_confidence(n) if n.domain == nom.domain else n
+                    for n in nominations
+                ]
+
+        # Step 4: Handle ML-only signals (ML says ESCALATION but no triggers)
+        if ml_label == "ESCALATION" and ml_confidence and ml_confidence > 0.5:
+            has_safety_trigger = any(
+                not n.is_negated and n.confidence_tier >= ConfidenceTier.LOW
+                for n in nominations
+                if n.domain in set(self._safety_precedence)
+            )
+            # Check if the ML is confused by negated safety keywords:
+            # If safety domains DID match but were ALL negated, the ML is
+            # likely reacting to the keywords themselves (e.g., "I'm NOT
+            # suicidal" triggers ML ESCALATION because it sees "suicidal").
+            # In this case, trust the explicit negation over the ML signal.
+            has_negated_safety = any(
+                n.is_negated
+                for n in nominations
+                if n.domain in set(self._safety_precedence)
+            )
+            if not has_safety_trigger and not has_negated_safety:
+                # ML detected escalation but no specific domain matched
+                # (and no negated safety domains either)
+                # Create a generic nomination so it's not silently dropped
+                nominations.append(
+                    DomainNomination(
+                        domain="unclassified_escalation",
+                        display_name="Unclassified Escalation",
+                        confidence_tier=self._ml_prob_to_tier(ml_confidence),
+                        priority=50,  # Middle priority
+                        target_risk_class=RiskClass.R2,
+                        trigger_matches=(),
+                        negation_result=None,
+                        ml_label=ml_label,
+                        ml_confidence=ml_confidence,
+                        recommended_flow="handoff",
+                    )
+                )
+
+        # Step 5: Handle ML reinforcement for non-escalation labels
+        if ml_label and ml_label != "ESCALATION":
+            hint_domains = _ML_LABEL_DOMAIN_HINTS.get(ml_label, [])
+            for nom in nominations:
+                if nom.domain in hint_domains and ml_confidence:
+                    # ML confirms trigger match — boost confidence if ML is strong
+                    if ml_confidence > 0.8 and nom.confidence_tier < ConfidenceTier.HIGH:
+                        nominations = [
+                            self._boost_confidence(n) if n.domain == nom.domain else n
+                            for n in nominations
+                        ]
+
+        # Step 6: Resolve recommended_flow for each nomination
+        nominations = [self._resolve_flow(n) for n in nominations]
+
+        # Step 7: Sort
+        nominations.sort(key=self._nomination_sort_key, reverse=True)
+
+        if nominations:
+            logger.info(
+                "Domain nominations for text (len=%d): %s",
+                len(text),
+                [(n.domain, n.confidence_tier.value, n.priority) for n in nominations[:5]],
+            )
+
+        return nominations
+
+    # ------------------------------------------------------------------
+    # Internal helpers
+    # ------------------------------------------------------------------
+
+    def _build_nomination(
+        self,
+        domain_name: str,
+        match_result: DomainMatchResult,
+        ml_label: Optional[str],
+        ml_confidence: Optional[float],
+    ) -> DomainNomination:
+        """Build a DomainNomination from a DomainMatchResult."""
+        # Get target risk class from rules.yaml
+        target_risk_str = self._config.get_domain_target_risk(domain_name)
+        target_risk = None
+        if target_risk_str:
+            try:
+                target_risk = RiskClass(target_risk_str)
+            except ValueError:
+                pass
+
+        return DomainNomination(
+            domain=domain_name,
+            display_name=domain_name.replace("_", " ").title(),
+            confidence_tier=match_result.effective_confidence,
+            priority=match_result.priority,
+            target_risk_class=target_risk,
+            trigger_matches=match_result.matches,
+            negation_result=match_result.negation_result,
+            ml_label=ml_label,
+            ml_confidence=ml_confidence,
+        )
+
+    def _resolve_flow(self, nomination: DomainNomination) -> DomainNomination:
+        """Determine recommended_flow from domain decision rules."""
+        if nomination.recommended_flow:
+            return nomination
+
+        rules = self._config.get_domain_decision_rules(nomination.domain)
+        if not rules:
+            return nomination
+
+        # Find first matching rule based on confidence tier
+        for rule in rules:
+            conditions = rule.get("if", {})
+            conf_required = conditions.get("confidence")
+            if conf_required and conf_required == nomination.confidence_tier.value:
+                flow = rule.get("then", {}).get("flow")
+                if flow:
+                    return DomainNomination(
+                        domain=nomination.domain,
+                        display_name=nomination.display_name,
+                        confidence_tier=nomination.confidence_tier,
+                        priority=nomination.priority,
+                        target_risk_class=nomination.target_risk_class,
+                        trigger_matches=nomination.trigger_matches,
+                        negation_result=nomination.negation_result,
+                        ml_label=nomination.ml_label,
+                        ml_confidence=nomination.ml_confidence,
+                        recommended_flow=flow,
+                    )
+
+        return nomination
+
+    def _force_high_confidence(
+        self, nomination: DomainNomination
+    ) -> DomainNomination:
+        """Force a nomination to HIGH confidence (for hard-escalate domains)."""
+        if nomination.confidence_tier == ConfidenceTier.HIGH:
+            return nomination
+        logger.warning(
+            "HARD ESCALATE: Forcing %s to HIGH confidence (was %s)",
+            nomination.domain,
+            nomination.confidence_tier.value,
+        )
+        return DomainNomination(
+            domain=nomination.domain,
+            display_name=nomination.display_name,
+            confidence_tier=ConfidenceTier.HIGH,
+            priority=nomination.priority,
+            target_risk_class=nomination.target_risk_class,
+            trigger_matches=nomination.trigger_matches,
+            negation_result=nomination.negation_result,
+            ml_label=nomination.ml_label,
+            ml_confidence=nomination.ml_confidence,
+            recommended_flow=nomination.recommended_flow,
+        )
+
+    def _boost_confidence(
+        self, nomination: DomainNomination
+    ) -> DomainNomination:
+        """Boost confidence by one tier when ML reinforces trigger."""
+        new_tier = nomination.confidence_tier
+        if new_tier == ConfidenceTier.LOW:
+            new_tier = ConfidenceTier.MEDIUM
+        elif new_tier == ConfidenceTier.MEDIUM:
+            new_tier = ConfidenceTier.HIGH
+        if new_tier == nomination.confidence_tier:
+            return nomination
+        return DomainNomination(
+            domain=nomination.domain,
+            display_name=nomination.display_name,
+            confidence_tier=new_tier,
+            priority=nomination.priority,
+            target_risk_class=nomination.target_risk_class,
+            trigger_matches=nomination.trigger_matches,
+            negation_result=nomination.negation_result,
+            ml_label=nomination.ml_label,
+            ml_confidence=nomination.ml_confidence,
+            recommended_flow=nomination.recommended_flow,
+        )
+
+    @staticmethod
+    def _ml_prob_to_tier(prob: float) -> ConfidenceTier:
+        """Map ML probability to a confidence tier."""
+        if prob >= 0.8:
+            return ConfidenceTier.HIGH
+        elif prob >= 0.5:
+            return ConfidenceTier.MEDIUM
+        elif prob >= 0.3:
+            return ConfidenceTier.LOW
+        return ConfidenceTier.NONE
+
+    @staticmethod
+    def _nomination_sort_key(
+        nom: DomainNomination,
+    ) -> Tuple[int, int, float]:
+        """Sort key: (confidence_rank, priority, ml_confidence)."""
+        conf_rank = {
+            ConfidenceTier.HIGH: 3,
+            ConfidenceTier.MEDIUM: 2,
+            ConfidenceTier.LOW: 1,
+            ConfidenceTier.NONE: 0,
+        }
+        return (
+            conf_rank.get(nom.confidence_tier, 0),
+            nom.priority,
+            nom.ml_confidence or 0.0,
+        )
diff --git a/decision/engine/fhir_context.py b/decision/engine/fhir_context.py
new file mode 100644
index 0000000000000000000000000000000000000000..5a964b344a59e4359783e86cb046f34971696679
--- /dev/null
+++ b/decision/engine/fhir_context.py
@@ -0,0 +1,506 @@
+"""
+FHIR Context Loader (Phase 3A).
+
+Builds a PatientContext from FHIR R4 resources for context-aware risk rules.
+
+Key features:
+  - Minimum necessary principle: only fetch resources needed for the active wedge
+  - Lookback periods: filter by date relevance
+  - Freshness detection: warn when clinical data is stale
+  - ICD-10 condition matching for risk rule evaluation
+  - Medication count for polypharmacy detection
+  - Pre-populated slot extraction for journey agendas
+
+This module provides:
+  1. PatientContext dataclass — normalized patient data for risk evaluation
+  2. PatientContextBuilder — builds context from raw FHIR bundles
+  3. FHIRClient (abstract) — interface for FHIR data fetching (Phase 3 full impl)
+
+Safety invariants:
+  - Missing context = fail closed (context-dependent rules don't fire)
+  - Stale data is flagged but still used (better than no data)
+  - PHI is never logged — only ICD codes and counts
+"""
+
+from __future__ import annotations
+
+import logging
+from dataclasses import dataclass, field
+from datetime import datetime, timedelta, timezone
+from typing import Any, Dict, List, Optional, Set
+
+from decision.engine.config_loader import DecisionConfigLoader
+
+logger = logging.getLogger("decision.fhir_context")
+
+
+# ---------------------------------------------------------------------------
+# Patient Context
+# ---------------------------------------------------------------------------
+
+@dataclass
+class PatientContext:
+    """
+    Normalized patient context for clinical decision-making.
+
+    Built from FHIR resources. Used by RiskClassifier for context-aware rules.
+    """
+    patient_id: str = ""
+
+    # Conditions (ICD-10 codes of active problems)
+    active_conditions: List[str] = field(default_factory=list)
+    # Convenience sets for common condition groups
+    has_chf: bool = False             # I50.*
+    has_copd: bool = False            # J44.*
+    has_diabetes: bool = False        # E10.*, E11.*
+    has_ckd: bool = False             # N18.*
+    has_cancer: bool = False          # C00-C97
+    has_afib: bool = False            # I48.*
+    has_depression: bool = False      # F32.*, F33.*
+    has_anxiety: bool = False         # F41.*
+
+    # Medications
+    active_medication_count: int = 0
+    active_medication_names: List[str] = field(default_factory=list)
+    is_on_anticoagulant: bool = False
+    is_on_insulin: bool = False
+    is_on_opioid: bool = False
+
+    # Demographics
+    age: Optional[int] = None
+    is_elderly: bool = False          # 65+
+    is_very_elderly: bool = False     # 75+
+
+    # Recent vitals
+    last_bp_systolic: Optional[float] = None
+    last_bp_diastolic: Optional[float] = None
+    last_heart_rate: Optional[float] = None
+    last_weight_kg: Optional[float] = None
+    last_glucose: Optional[float] = None
+    last_temperature: Optional[float] = None
+
+    # Recent encounter
+    days_since_discharge: Optional[int] = None
+    discharge_diagnosis_codes: List[str] = field(default_factory=list)
+
+    # Allergies
+    allergy_count: int = 0
+    drug_allergies: List[str] = field(default_factory=list)
+
+    # Appointments
+    has_upcoming_appointment: bool = False
+    next_appointment_days: Optional[int] = None
+
+    # Freshness / staleness warnings
+    stale_resources: List[str] = field(default_factory=list)
+    context_timestamp: Optional[datetime] = None
+
+    def to_risk_context(self) -> Dict[str, Any]:
+        """
+        Convert to the dict format expected by RiskClassifier.assess(patient_context=...).
+        """
+        return {
+            "patient_id": self.patient_id,
+            "active_conditions": self.active_conditions,
+            "active_medication_count": self.active_medication_count,
+            "has_chf": self.has_chf,
+            "has_copd": self.has_copd,
+            "has_diabetes": self.has_diabetes,
+            "has_ckd": self.has_ckd,
+            "has_cancer": self.has_cancer,
+            "has_afib": self.has_afib,
+            "has_depression": self.has_depression,
+            "has_anxiety": self.has_anxiety,
+            "is_on_anticoagulant": self.is_on_anticoagulant,
+            "is_on_insulin": self.is_on_insulin,
+            "is_on_opioid": self.is_on_opioid,
+            "age": self.age,
+            "is_elderly": self.is_elderly,
+            "is_very_elderly": self.is_very_elderly,
+            "days_since_discharge": self.days_since_discharge,
+            "stale_resources": self.stale_resources,
+        }
+
+
+# ---------------------------------------------------------------------------
+# Patient Context Builder
+# ---------------------------------------------------------------------------
+
+# ICD-10 pattern groups for condition detection
+_CONDITION_GROUPS = {
+    "has_chf": ["I50"],
+    "has_copd": ["J44"],
+    "has_diabetes": ["E10", "E11"],
+    "has_ckd": ["N18"],
+    "has_cancer": [f"C{i:02d}" for i in range(98)],  # C00-C97
+    "has_afib": ["I48"],
+    "has_depression": ["F32", "F33"],
+    "has_anxiety": ["F41"],
+}
+
+# Medication class detection (by name substring)
+_ANTICOAGULANTS = {"warfarin", "coumadin", "heparin", "enoxaparin", "lovenox",
+                   "apixaban", "eliquis", "rivaroxaban", "xarelto", "dabigatran", "pradaxa"}
+_INSULINS = {"insulin", "humalog", "novolog", "lantus", "levemir", "tresiba",
+             "basaglar", "admelog", "fiasp", "toujeo"}
+_OPIOIDS = {"oxycodone", "hydrocodone", "morphine", "fentanyl", "codeine",
+            "tramadol", "methadone", "hydromorphone", "oxymorphone", "dilaudid",
+            "percocet", "vicodin", "norco"}
+
+
+class PatientContextBuilder:
+    """
+    Builds a PatientContext from FHIR resource bundles.
+
+    Usage:
+        builder = PatientContextBuilder(config)
+        context = builder.build_from_fhir(
+            patient_id="P-123",
+            fhir_bundle=bundle_dict,
+            wedge_type="pde",
+        )
+    """
+
+    def __init__(self, config: DecisionConfigLoader):
+        self._config = config
+        self._fhir_mappings = config.fhir_mappings
+        self._freshness_thresholds = self._fhir_mappings.get("freshness_thresholds", {})
+
+    def build_from_fhir(
+        self,
+        patient_id: str,
+        fhir_bundle: Dict[str, Any],
+        wedge_type: Optional[str] = None,
+    ) -> PatientContext:
+        """
+        Build PatientContext from a FHIR bundle response.
+
+        Args:
+            patient_id: Patient identifier
+            fhir_bundle: FHIR Bundle resource (or dict of resource lists)
+            wedge_type: Active wedge for minimum necessary filtering
+
+        Returns:
+            PatientContext ready for risk rule evaluation
+        """
+        ctx = PatientContext(
+            patient_id=patient_id,
+            context_timestamp=datetime.now(timezone.utc),
+        )
+
+        # Extract resources from bundle
+        resources = self._extract_resources(fhir_bundle)
+
+        # Build context from each resource type
+        self._process_patient(ctx, resources.get("Patient", []))
+        self._process_conditions(ctx, resources.get("Condition", []))
+        self._process_medications(ctx, resources.get("MedicationRequest", []))
+        self._process_observations(ctx, resources.get("Observation", []))
+        self._process_allergies(ctx, resources.get("AllergyIntolerance", []))
+        self._process_encounters(ctx, resources.get("Encounter", []))
+        self._process_appointments(ctx, resources.get("Appointment", []))
+
+        # Check freshness
+        self._check_freshness(ctx, resources)
+
+        logger.info(
+            "PatientContext built: patient=%s conditions=%d meds=%d age=%s chf=%s copd=%s dm=%s",
+            patient_id,
+            len(ctx.active_conditions),
+            ctx.active_medication_count,
+            ctx.age,
+            ctx.has_chf,
+            ctx.has_copd,
+            ctx.has_diabetes,
+        )
+
+        return ctx
+
+    def build_from_dict(
+        self,
+        patient_id: str,
+        data: Dict[str, Any],
+    ) -> PatientContext:
+        """
+        Build PatientContext from a pre-processed dict (e.g., from API request).
+
+        This allows callers to pass patient context directly without FHIR.
+        """
+        ctx = PatientContext(
+            patient_id=patient_id,
+            context_timestamp=datetime.now(timezone.utc),
+        )
+
+        ctx.active_conditions = data.get("active_conditions", [])
+        ctx.active_medication_count = data.get("active_medication_count", 0)
+        ctx.active_medication_names = data.get("active_medication_names", [])
+        ctx.age = data.get("age")
+        ctx.days_since_discharge = data.get("days_since_discharge")
+
+        # Derive flags from conditions
+        self._set_condition_flags(ctx)
+
+        # Derive flags from medications
+        self._set_medication_flags(ctx)
+
+        # Age flags
+        if ctx.age:
+            ctx.is_elderly = ctx.age >= 65
+            ctx.is_very_elderly = ctx.age >= 75
+
+        return ctx
+
+    # ------------------------------------------------------------------
+    # Resource processing
+    # ------------------------------------------------------------------
+
+    def _extract_resources(
+        self, bundle: Dict[str, Any]
+    ) -> Dict[str, List[Dict[str, Any]]]:
+        """Extract resources from a FHIR Bundle, grouped by resourceType."""
+        resources: Dict[str, List[Dict[str, Any]]] = {}
+
+        # Handle standard FHIR Bundle format
+        entries = bundle.get("entry", [])
+        for entry in entries:
+            resource = entry.get("resource", {})
+            rtype = resource.get("resourceType", "Unknown")
+            resources.setdefault(rtype, []).append(resource)
+
+        # Also handle flat dict format {resourceType: [resources]}
+        for key, value in bundle.items():
+            if key != "entry" and isinstance(value, list):
+                resources.setdefault(key, []).extend(value)
+
+        return resources
+
+    def _process_patient(
+        self, ctx: PatientContext, patients: List[Dict[str, Any]]
+    ) -> None:
+        if not patients:
+            return
+        patient = patients[0]
+        birth_date = patient.get("birthDate")
+        if birth_date:
+            try:
+                dob = datetime.strptime(birth_date, "%Y-%m-%d")
+                today = datetime.now()
+                ctx.age = today.year - dob.year - ((today.month, today.day) < (dob.month, dob.day))
+                ctx.is_elderly = ctx.age >= 65
+                ctx.is_very_elderly = ctx.age >= 75
+            except (ValueError, TypeError):
+                pass
+
+    def _process_conditions(
+        self, ctx: PatientContext, conditions: List[Dict[str, Any]]
+    ) -> None:
+        for condition in conditions:
+            # Only active conditions
+            clinical_status = condition.get("clinicalStatus", {})
+            if isinstance(clinical_status, dict):
+                codings = clinical_status.get("coding", [])
+                status_code = codings[0].get("code", "") if codings else ""
+            else:
+                status_code = str(clinical_status)
+
+            if status_code and status_code not in ("active", "recurrence", "relapse"):
+                continue
+
+            # Extract ICD-10 codes
+            code_concept = condition.get("code", {})
+            for coding in code_concept.get("coding", []):
+                system = coding.get("system", "")
+                code = coding.get("code", "")
+                if "icd" in system.lower() or code:
+                    ctx.active_conditions.append(code)
+
+        self._set_condition_flags(ctx)
+
+    def _set_condition_flags(self, ctx: PatientContext) -> None:
+        """Set boolean condition flags from ICD-10 codes."""
+        for flag_name, prefixes in _CONDITION_GROUPS.items():
+            has_condition = any(
+                any(code.startswith(prefix) for prefix in prefixes)
+                for code in ctx.active_conditions
+            )
+            setattr(ctx, flag_name, has_condition)
+
+    def _process_medications(
+        self, ctx: PatientContext, medications: List[Dict[str, Any]]
+    ) -> None:
+        active_meds = []
+        for med in medications:
+            status = med.get("status", "")
+            if status not in ("active", "completed"):
+                continue
+            med_name = ""
+            med_concept = med.get("medicationCodeableConcept", {})
+            if med_concept:
+                med_name = med_concept.get("text", "")
+                if not med_name:
+                    codings = med_concept.get("coding", [])
+                    if codings:
+                        med_name = codings[0].get("display", "")
+            if med_name:
+                active_meds.append(med_name)
+
+        ctx.active_medication_names = active_meds
+        ctx.active_medication_count = len(active_meds)
+        self._set_medication_flags(ctx)
+
+    def _set_medication_flags(self, ctx: PatientContext) -> None:
+        """Set medication class flags from med names."""
+        names_lower = {n.lower() for n in ctx.active_medication_names}
+        ctx.is_on_anticoagulant = bool(names_lower & _ANTICOAGULANTS)
+        ctx.is_on_insulin = bool(names_lower & _INSULINS)
+        ctx.is_on_opioid = bool(names_lower & _OPIOIDS)
+
+    def _process_observations(
+        self, ctx: PatientContext, observations: List[Dict[str, Any]]
+    ) -> None:
+        # Sort by date descending to get most recent first
+        observations.sort(
+            key=lambda o: o.get("effectiveDateTime", ""),
+            reverse=True,
+        )
+
+        for obs in observations:
+            code_concept = obs.get("code", {})
+            codings = code_concept.get("coding", [])
+            loinc_code = ""
+            for coding in codings:
+                if "loinc" in coding.get("system", "").lower():
+                    loinc_code = coding.get("code", "")
+                    break
+
+            value = obs.get("valueQuantity", {}).get("value")
+            if value is None:
+                continue
+
+            # Map LOINC codes to context fields (most recent only)
+            if loinc_code == "8480-6" and ctx.last_bp_systolic is None:  # Systolic BP
+                ctx.last_bp_systolic = float(value)
+            elif loinc_code == "8462-4" and ctx.last_bp_diastolic is None:  # Diastolic BP
+                ctx.last_bp_diastolic = float(value)
+            elif loinc_code == "8867-4" and ctx.last_heart_rate is None:  # Heart rate
+                ctx.last_heart_rate = float(value)
+            elif loinc_code == "29463-7" and ctx.last_weight_kg is None:  # Weight
+                ctx.last_weight_kg = float(value)
+            elif loinc_code in ("2339-0", "2345-7") and ctx.last_glucose is None:  # Glucose
+                ctx.last_glucose = float(value)
+            elif loinc_code == "8310-5" and ctx.last_temperature is None:  # Temperature
+                ctx.last_temperature = float(value)
+
+    def _process_allergies(
+        self, ctx: PatientContext, allergies: List[Dict[str, Any]]
+    ) -> None:
+        active_allergies = [
+            a for a in allergies
+            if a.get("clinicalStatus", {}).get("coding", [{}])[0].get("code") == "active"
+            or not a.get("clinicalStatus")
+        ]
+        ctx.allergy_count = len(active_allergies)
+
+        for allergy in active_allergies:
+            category = allergy.get("category", [])
+            if "medication" in category:
+                substance = allergy.get("code", {}).get("text", "")
+                if substance:
+                    ctx.drug_allergies.append(substance)
+
+    def _process_encounters(
+        self, ctx: PatientContext, encounters: List[Dict[str, Any]]
+    ) -> None:
+        # Find most recent discharge
+        encounters.sort(
+            key=lambda e: e.get("period", {}).get("end", ""),
+            reverse=True,
+        )
+
+        for enc in encounters:
+            period = enc.get("period", {})
+            end_date = period.get("end")
+            if not end_date:
+                continue
+            try:
+                discharge_dt = datetime.fromisoformat(end_date.replace("Z", "+00:00"))
+                now = datetime.now(timezone.utc)
+                delta = now - discharge_dt
+                ctx.days_since_discharge = delta.days
+
+                # Extract discharge diagnosis codes
+                diagnoses = enc.get("diagnosis", [])
+                for diag in diagnoses:
+                    code = diag.get("condition", {}).get("reference", "")
+                    if code:
+                        ctx.discharge_diagnosis_codes.append(code)
+                break  # Most recent only
+            except (ValueError, TypeError):
+                continue
+
+    def _process_appointments(
+        self, ctx: PatientContext, appointments: List[Dict[str, Any]]
+    ) -> None:
+        now = datetime.now(timezone.utc)
+        for appt in appointments:
+            status = appt.get("status", "")
+            if status in ("cancelled", "noshow", "entered-in-error"):
+                continue
+            start = appt.get("start")
+            if not start:
+                continue
+            try:
+                appt_dt = datetime.fromisoformat(start.replace("Z", "+00:00"))
+                if appt_dt > now:
+                    ctx.has_upcoming_appointment = True
+                    delta = appt_dt - now
+                    if ctx.next_appointment_days is None or delta.days < ctx.next_appointment_days:
+                        ctx.next_appointment_days = delta.days
+            except (ValueError, TypeError):
+                continue
+
+    def _check_freshness(
+        self, ctx: PatientContext, resources: Dict[str, List[Dict[str, Any]]]
+    ) -> None:
+        """Check resource freshness against configured thresholds."""
+        now = datetime.now(timezone.utc)
+
+        for resource_type, threshold_hours in self._freshness_thresholds.items():
+            if threshold_hours is None:
+                continue
+
+            # Map compound types (e.g., "Observation_laboratory") to base type
+            base_type = resource_type.split("_")[0]
+            entries = resources.get(base_type, [])
+            if not entries:
+                continue
+
+            # Find most recent entry date
+            latest_date = None
+            for entry in entries:
+                date_str = (
+                    entry.get("effectiveDateTime")
+                    or entry.get("authoredOn")
+                    or entry.get("recordedDate")
+                    or entry.get("meta", {}).get("lastUpdated")
+                )
+                if date_str:
+                    try:
+                        dt = datetime.fromisoformat(date_str.replace("Z", "+00:00"))
+                        if latest_date is None or dt > latest_date:
+                            latest_date = dt
+                    except (ValueError, TypeError):
+                        continue
+
+            if latest_date:
+                hours_old = (now - latest_date).total_seconds() / 3600
+                if hours_old > threshold_hours:
+                    ctx.stale_resources.append(
+                        f"{resource_type} (last updated {hours_old:.0f}h ago, threshold {threshold_hours}h)"
+                    )
+                    logger.warning(
+                        "Stale FHIR data: %s is %.0fh old (threshold: %dh)",
+                        resource_type,
+                        hours_old,
+                        threshold_hours,
+                    )
diff --git a/decision/engine/flow_engine.py b/decision/engine/flow_engine.py
new file mode 100644
index 0000000000000000000000000000000000000000..74d0e8a4b2498d1f312b6583b46a8b08036e2246
--- /dev/null
+++ b/decision/engine/flow_engine.py
@@ -0,0 +1,763 @@
+"""
+Flow Execution Engine (Phase 2A).
+
+Manages multi-step clinical conversation flows with:
+  - State machine for flow step progression
+  - Slot tracking and validation
+  - Response spec enforcement (must_include, must_not, max_questions)
+  - Primitive sequence execution (greeting → identity_verify → consent)
+  - Domain-specific flow routing from risk assessment
+  - Exit condition evaluation
+
+Safety invariants:
+  - Escalation flows CANNOT be interrupted or rolled back
+  - Hard-escalate domains skip screening and go directly to escalate_r3
+  - If unclear at any step, fail open (escalate, not suppress)
+  - Response specs enforce must_not constraints — these are NEVER relaxed
+"""
+
+from __future__ import annotations
+
+import logging
+from typing import Any, Dict, List, Optional, Set, Tuple
+
+from decision.engine.config_loader import DecisionConfigLoader
+from decision.engine.models import (
+    CallPhase,
+    ConfidenceTier,
+    ConversationFlow,
+    FlowStep,
+    FlowType,
+    ResponseSpec,
+    RiskAssessment,
+    RiskClass,
+    SessionState,
+    SlotState,
+    TurnOutcome,
+)
+
+logger = logging.getLogger("decision.flow_engine")
+
+
+# ---------------------------------------------------------------------------
+# Flow Resolution
+# ---------------------------------------------------------------------------
+
+class FlowResolver:
+    """
+    Resolves which conversation flow to execute based on the current
+    session state, risk assessment, and domain rules.
+    """
+
+    def __init__(self, config: DecisionConfigLoader):
+        self._config = config
+        self._primitives = config.primitives
+        self._taxonomy_flows = config.taxonomy_flows
+        self._taxonomy_rules = config.taxonomy_rules
+        self._primitive_sequence = config.global_rules.get("primitive_sequence", [])
+        self._fallback_flow = config.global_rules.get("fallback_flow", "primitives/clarify")
+
+    def resolve_initial_flow(self, session: SessionState) -> Optional[FlowDefinition]:
+        """Resolve the first flow to execute when a call starts."""
+        if self._primitive_sequence:
+            first = self._primitive_sequence[0]
+            return self._load_primitive(first)
+        return None
+
+    def resolve_next_flow(
+        self,
+        session: SessionState,
+        assessment: Optional[RiskAssessment] = None,
+        current_exit: Optional[str] = None,
+    ) -> Optional[FlowDefinition]:
+        """
+        Resolve the next flow based on current state and exit condition.
+
+        Priority order:
+          1. Hard-escalate → escalate_r3 (immediate, cannot be overridden)
+          2. R3 assessment → domain escalate_r3 flow
+          3. R2 assessment → domain escalate_r2 flow
+          4. Explicit exit rule (on_complete, on_refused, etc.)
+          5. Primitive sequence (if still in opening)
+          6. Domain-specific recommended_flow from assessment
+          7. Fallback → clarify
+        """
+        # 1. Hard escalate overrides everything
+        if assessment and assessment.hard_escalate:
+            domain = assessment.primary_domain or "suicidal_ideation"
+            flow = self._load_domain_flow(domain, "escalate_r3")
+            if flow:
+                logger.warning("HARD ESCALATE: routing to %s/escalate_r3", domain)
+                return flow
+            # Fallback to generic handoff
+            return self._load_primitive("handoff")
+
+        # 2-3. Risk-based routing
+        if assessment and assessment.risk_class == RiskClass.R3:
+            domain = assessment.primary_domain
+            if domain:
+                flow = self._load_domain_flow(domain, "escalate_r3")
+                if flow:
+                    return flow
+            return self._load_primitive("handoff")
+
+        if assessment and assessment.risk_class == RiskClass.R2:
+            domain = assessment.primary_domain
+            if domain:
+                flow = self._load_domain_flow(domain, "escalate_r2")
+                if flow:
+                    return flow
+            return self._load_primitive("handoff")
+
+        # 4. Explicit exit rule
+        if current_exit:
+            return self._resolve_exit(current_exit, session)
+
+        # 5. Check if still in primitive sequence
+        prim_flow = self._advance_primitive_sequence(session)
+        if prim_flow:
+            return prim_flow
+
+        # 6. Domain recommended flow
+        if assessment and assessment.recommended_flow:
+            domain = assessment.primary_domain
+            if domain:
+                flow = self._load_domain_flow(domain, assessment.recommended_flow)
+                if flow:
+                    return flow
+
+        # 7. Fallback
+        return self._load_primitive("clarify")
+
+    def _resolve_exit(
+        self, exit_key: str, session: SessionState
+    ) -> Optional[FlowDefinition]:
+        """Resolve an exit rule like 'on_complete', 'on_refused', etc."""
+        # Special exit targets
+        if exit_key == "end":
+            return None  # Session over
+        if exit_key == "re_evaluate":
+            return None  # Signal to re-run assessment
+        if exit_key == "evaluate_risk":
+            return None  # Signal to run risk evaluation
+        if exit_key == "evaluate_concern":
+            return None  # Signal to evaluate a patient concern
+
+        # Try as primitive name
+        prim = self._load_primitive(exit_key)
+        if prim:
+            return prim
+
+        # Try as domain flow (format: "domain/flow_id" or just "flow_id")
+        if "/" in exit_key:
+            domain, flow_id = exit_key.split("/", 1)
+            return self._load_domain_flow(domain, flow_id)
+
+        return None
+
+    def _advance_primitive_sequence(
+        self, session: SessionState
+    ) -> Optional[FlowDefinition]:
+        """Check if the session still needs to complete primitive sequence."""
+        if session.call_phase != CallPhase.SESSION_START:
+            return None
+
+        completed = set(session.domain_history)
+        for prim_name in self._primitive_sequence:
+            if prim_name not in completed:
+                return self._load_primitive(prim_name)
+
+        # All primitives complete — advance to active call phase
+        return None
+
+    def _load_primitive(self, name: str) -> Optional[FlowDefinition]:
+        """Load a primitive flow definition by name."""
+        data = self._primitives.get(name)
+        if not data:
+            return None
+        return FlowDefinition.from_yaml(data, source=f"primitives/{name}")
+
+    def _load_domain_flow(
+        self, domain: str, flow_id: str
+    ) -> Optional[FlowDefinition]:
+        """Load a domain-specific flow definition."""
+        domain_flows = self._taxonomy_flows.get(domain, {})
+        data = domain_flows.get(flow_id)
+        if not data:
+            return None
+        return FlowDefinition.from_yaml(data, source=f"taxonomy/{domain}/{flow_id}")
+
+
+# ---------------------------------------------------------------------------
+# Flow Definition (parsed from YAML)
+# ---------------------------------------------------------------------------
+
+class FlowDefinition:
+    """A parsed conversation flow with steps and exit rules."""
+
+    def __init__(
+        self,
+        flow_id: str,
+        flow_type: str,
+        domain: Optional[str],
+        required_slots: List[str],
+        steps: List[FlowStepDef],
+        exit_rules: Dict[str, str],
+        source: str = "",
+    ):
+        self.flow_id = flow_id
+        self.flow_type = flow_type
+        self.domain = domain
+        self.required_slots = required_slots
+        self.steps = steps
+        self.exit_rules = exit_rules
+        self.source = source
+
+    @classmethod
+    def from_yaml(cls, data: Dict[str, Any], source: str = "") -> FlowDefinition:
+        """Parse a flow definition from YAML data."""
+        flow_id = data.get("flow_id", "unknown")
+        flow_type = data.get("type", "primitive")
+        domain = data.get("domain")
+        required_slots = data.get("required_slots", [])
+        exit_rules = data.get("exit", {})
+
+        steps = []
+        for action in data.get("actions", []):
+            step = FlowStepDef.from_yaml(action)
+            steps.append(step)
+
+        return cls(
+            flow_id=flow_id,
+            flow_type=flow_type,
+            domain=domain,
+            required_slots=required_slots,
+            steps=steps,
+            exit_rules=exit_rules,
+            source=source,
+        )
+
+    @property
+    def step_count(self) -> int:
+        return len(self.steps)
+
+    def get_step(self, index: int) -> Optional[FlowStepDef]:
+        if 0 <= index < len(self.steps):
+            return self.steps[index]
+        return None
+
+    def __repr__(self) -> str:
+        return f"FlowDefinition({self.flow_id}, type={self.flow_type}, steps={self.step_count})"
+
+
+class FlowStepDef:
+    """A single step in a flow, parsed from YAML."""
+
+    def __init__(
+        self,
+        step_number: int,
+        step_type: str,
+        response_spec: ResponseSpecDef,
+        collects: List[str],
+        handoff_target: Optional[str] = None,
+        handoff_urgency: Optional[str] = None,
+    ):
+        self.step_number = step_number
+        self.step_type = step_type
+        self.response_spec = response_spec
+        self.collects = collects
+        self.handoff_target = handoff_target
+        self.handoff_urgency = handoff_urgency
+
+    @classmethod
+    def from_yaml(cls, data: Dict[str, Any]) -> FlowStepDef:
+        step_number = data.get("step", 0)
+        step_type = data.get("type", "respond")
+        spec_data = data.get("response_spec", {})
+        response_spec = ResponseSpecDef.from_yaml(spec_data)
+        collects = data.get("collects", [])
+        handoff_target = data.get("target")
+        handoff_urgency = data.get("urgency")
+
+        return cls(
+            step_number=step_number,
+            step_type=step_type,
+            response_spec=response_spec,
+            collects=collects,
+            handoff_target=handoff_target,
+            handoff_urgency=handoff_urgency,
+        )
+
+
+class ResponseSpecDef:
+    """LLM response constraints parsed from YAML."""
+
+    def __init__(
+        self,
+        spec_id: str,
+        goal: str,
+        tone: str,
+        must_include: List[str],
+        must_ask: List[str],
+        must_not: List[str],
+        max_questions: int,
+    ):
+        self.spec_id = spec_id
+        self.goal = goal
+        self.tone = tone
+        self.must_include = must_include
+        self.must_ask = must_ask
+        self.must_not = must_not
+        self.max_questions = max_questions
+
+    @classmethod
+    def from_yaml(cls, data: Dict[str, Any]) -> ResponseSpecDef:
+        return cls(
+            spec_id=data.get("id", ""),
+            goal=data.get("goal", ""),
+            tone=data.get("tone", "professional"),
+            must_include=data.get("must_include", []),
+            must_ask=data.get("must_ask", []),
+            must_not=data.get("must_not", []),
+            max_questions=data.get("max_questions", 0),
+        )
+
+    def validate_response(self, response_text: str) -> List[str]:
+        """
+        Validate an LLM-generated response against this spec.
+        Returns list of violations (empty = valid).
+        """
+        violations = []
+        response_lower = response_text.lower()
+
+        # Check must_include
+        for phrase in self.must_include:
+            if phrase.lower() not in response_lower:
+                violations.append(f"MISSING required phrase: '{phrase}'")
+
+        # Check must_not — SAFETY CRITICAL, never relaxed
+        for phrase in self.must_not:
+            if phrase.lower() in response_lower:
+                violations.append(f"FORBIDDEN phrase found: '{phrase}'")
+
+        # Check max_questions (count question marks)
+        question_count = response_text.count("?")
+        if question_count > self.max_questions and self.max_questions >= 0:
+            violations.append(
+                f"Too many questions: {question_count} > max {self.max_questions}"
+            )
+
+        return violations
+
+    def to_prompt_constraints(self) -> str:
+        """Generate constraint text for LLM prompt injection."""
+        lines = [f"Goal: {self.goal}", f"Tone: {self.tone}"]
+        if self.must_include:
+            lines.append(f"Must include: {', '.join(self.must_include)}")
+        if self.must_ask:
+            lines.append(f"Must ask about: {', '.join(self.must_ask)}")
+        if self.must_not:
+            lines.append(f"NEVER say: {', '.join(self.must_not)}")
+        if self.max_questions >= 0:
+            lines.append(f"Maximum questions: {self.max_questions}")
+        return "\n".join(lines)
+
+
+# ---------------------------------------------------------------------------
+# Flow Execution Engine
+# ---------------------------------------------------------------------------
+
+class FlowEngine:
+    """
+    Executes conversation flows and manages session state.
+
+    Usage:
+        engine = FlowEngine(config)
+        session = engine.create_session("session-123")
+        
+        # Start call
+        result = engine.start_call(session)
+        # result.response_spec has what Avery should say
+        
+        # Process patient response
+        result = engine.process_turn(session, patient_text, assessment)
+        # result tells you: next response_spec, slots collected, flow status
+    """
+
+    def __init__(self, config: DecisionConfigLoader):
+        self._config = config
+        self._resolver = FlowResolver(config)
+        self._sessions: Dict[str, SessionState] = {}
+
+    def create_session(
+        self,
+        session_id: str,
+        patient_id: Optional[str] = None,
+        tenant_id: Optional[str] = None,
+    ) -> SessionState:
+        """Create a new call session."""
+        session = SessionState(
+            session_id=session_id,
+            patient_id=patient_id,
+            tenant_id=tenant_id,
+            call_phase=CallPhase.SESSION_START,
+        )
+        self._sessions[session_id] = session
+        logger.info("Session created: %s (patient=%s, tenant=%s)", session_id, patient_id, tenant_id)
+        return session
+
+    def get_session(self, session_id: str) -> Optional[SessionState]:
+        """Retrieve an existing session."""
+        return self._sessions.get(session_id)
+
+    def destroy_session(self, session_id: str) -> None:
+        """Destroy a session."""
+        self._sessions.pop(session_id, None)
+
+    def start_call(self, session: SessionState) -> TurnResult:
+        """
+        Start a new call — returns the first flow step (greeting).
+        """
+        flow = self._resolver.resolve_initial_flow(session)
+        if not flow:
+            return TurnResult(
+                outcome=TurnOutcome.END,
+                message="No initial flow available",
+            )
+
+        session.current_flow = flow.flow_id
+        session.current_step = 0
+
+        step = flow.get_step(0)
+        if not step:
+            return TurnResult(outcome=TurnOutcome.END, message="Flow has no steps")
+
+        return TurnResult(
+            outcome=TurnOutcome.PROCEED,
+            flow_id=flow.flow_id,
+            flow_type=flow.flow_type,
+            step_number=0,
+            step_type=step.step_type,
+            response_spec=step.response_spec,
+            collects=step.collects,
+            handoff_target=step.handoff_target,
+            handoff_urgency=step.handoff_urgency,
+        )
+
+    def process_turn(
+        self,
+        session: SessionState,
+        patient_text: str,
+        assessment: Optional[RiskAssessment] = None,
+        extracted_slots: Optional[Dict[str, Any]] = None,
+    ) -> TurnResult:
+        """
+        Process a patient turn and determine the next action.
+
+        Args:
+            session: Current session state
+            patient_text: What the patient said
+            assessment: Risk assessment from Phase 1 engine
+            extracted_slots: Slots extracted from patient text (by NLU)
+
+        Returns:
+            TurnResult with next response_spec or escalation action
+        """
+        session.turn_count += 1
+
+        # Update slots from extracted values
+        if extracted_slots:
+            for k, v in extracted_slots.items():
+                session.slots.set_slot(k, v)
+
+        # SAFETY CHECK: If assessment triggers R3/hard_escalate, interrupt immediately
+        if assessment and (assessment.hard_escalate or assessment.risk_class == RiskClass.R3):
+            return self._handle_emergency_escalation(session, assessment)
+
+        if assessment and assessment.risk_class == RiskClass.R2:
+            return self._handle_nurse_transfer(session, assessment)
+
+        # Get current flow
+        current_flow = self._get_current_flow(session)
+        if not current_flow:
+            # No active flow — resolve from assessment
+            flow = self._resolver.resolve_next_flow(session, assessment)
+            if not flow:
+                return TurnResult(outcome=TurnOutcome.END, message="No applicable flow")
+            return self._enter_flow(session, flow)
+
+        # Advance to next step in current flow
+        return self._advance_flow(session, current_flow, assessment)
+
+    def _handle_emergency_escalation(
+        self, session: SessionState, assessment: RiskAssessment
+    ) -> TurnResult:
+        """Handle R3 / hard-escalate — interrupt everything, route to escalation."""
+        domain = assessment.primary_domain or "unknown"
+        session.call_phase = CallPhase.ENDED
+
+        # Try to load domain-specific escalation flow
+        flow = self._resolver.resolve_next_flow(session, assessment)
+        if flow and flow.steps:
+            step = flow.get_step(0)
+            logger.warning(
+                "EMERGENCY ESCALATION: session=%s domain=%s risk=%s",
+                session.session_id, domain, assessment.risk_class.value,
+            )
+            return TurnResult(
+                outcome=TurnOutcome.ESCALATE,
+                flow_id=flow.flow_id,
+                flow_type=flow.flow_type,
+                step_number=0,
+                step_type=step.step_type if step else "respond",
+                response_spec=step.response_spec if step else None,
+                handoff_target=step.handoff_target if step else "clinical_nurse",
+                handoff_urgency="immediate",
+                risk_class=assessment.risk_class,
+                domain=domain,
+                message=f"R3 EMERGENCY: {domain}",
+            )
+
+        # Fallback: generic escalation
+        return TurnResult(
+            outcome=TurnOutcome.ESCALATE,
+            handoff_target="clinical_nurse",
+            handoff_urgency="immediate",
+            risk_class=assessment.risk_class,
+            domain=domain,
+            message=f"R3 EMERGENCY: {domain} — transfer to nurse immediately",
+        )
+
+    def _handle_nurse_transfer(
+        self, session: SessionState, assessment: RiskAssessment
+    ) -> TurnResult:
+        """Handle R2 — warm transfer to nurse."""
+        domain = assessment.primary_domain or "unknown"
+
+        flow = self._resolver.resolve_next_flow(session, assessment)
+        if flow and flow.steps:
+            step = flow.get_step(0)
+            return TurnResult(
+                outcome=TurnOutcome.HANDOFF,
+                flow_id=flow.flow_id,
+                flow_type=flow.flow_type,
+                step_number=0,
+                step_type=step.step_type if step else "respond",
+                response_spec=step.response_spec if step else None,
+                handoff_target=step.handoff_target if step else "clinical_nurse",
+                handoff_urgency="soon",
+                risk_class=assessment.risk_class,
+                domain=domain,
+                message=f"R2: {domain} — schedule nurse callback",
+            )
+
+        return TurnResult(
+            outcome=TurnOutcome.HANDOFF,
+            handoff_target="clinical_nurse",
+            handoff_urgency="soon",
+            risk_class=assessment.risk_class,
+            domain=domain,
+            message=f"R2: {domain} — schedule nurse callback",
+        )
+
+    def _enter_flow(self, session: SessionState, flow: FlowDefinition) -> TurnResult:
+        """Enter a new flow and return the first step."""
+        session.current_flow = flow.flow_id
+        session.current_step = 0
+        session.domain_history.append(flow.flow_id)
+
+        step = flow.get_step(0)
+        if not step:
+            return TurnResult(outcome=TurnOutcome.PROCEED, message="Flow has no steps")
+
+        return TurnResult(
+            outcome=TurnOutcome.PROCEED,
+            flow_id=flow.flow_id,
+            flow_type=flow.flow_type,
+            step_number=0,
+            step_type=step.step_type,
+            response_spec=step.response_spec,
+            collects=step.collects,
+            handoff_target=step.handoff_target,
+            handoff_urgency=step.handoff_urgency,
+        )
+
+    def _advance_flow(
+        self,
+        session: SessionState,
+        flow: FlowDefinition,
+        assessment: Optional[RiskAssessment],
+    ) -> TurnResult:
+        """Advance to the next step in the current flow."""
+        next_step_idx = session.current_step + 1
+
+        if next_step_idx < flow.step_count:
+            # Move to next step
+            session.current_step = next_step_idx
+            step = flow.get_step(next_step_idx)
+
+            return TurnResult(
+                outcome=TurnOutcome.PROCEED,
+                flow_id=flow.flow_id,
+                flow_type=flow.flow_type,
+                step_number=next_step_idx,
+                step_type=step.step_type,
+                response_spec=step.response_spec,
+                collects=step.collects,
+                handoff_target=step.handoff_target,
+                handoff_urgency=step.handoff_urgency,
+            )
+
+        # Flow complete — evaluate exit rules
+        exit_rules = flow.exit_rules
+        exit_target = exit_rules.get("on_complete", "end")
+
+        # Check for special exits based on slot values
+        if "on_refused" in exit_rules and session.slots.get_slot("consent_given") == "no":
+            exit_target = exit_rules["on_refused"]
+        if "on_unclear" in exit_rules and session.slots.get_slot("clarification_text") is None:
+            exit_target = exit_rules.get("on_unclear", exit_target)
+        if "on_concern" in exit_rules:
+            # Check if any concern was raised during the flow
+            concern_slots = ["pain_level", "medication_adherence"]
+            for slot in concern_slots:
+                val = session.slots.get_slot(slot)
+                if val and isinstance(val, str) and any(w in val.lower() for w in ["severe", "bad", "not taking", "stopped"]):
+                    exit_target = exit_rules["on_concern"]
+                    break
+
+        # Reset current flow
+        session.current_flow = None
+        session.current_step = 0
+
+        if exit_target == "end":
+            session.call_phase = CallPhase.ENDED
+            return TurnResult(outcome=TurnOutcome.END, message="Flow complete")
+
+        if exit_target == "re_evaluate" or exit_target == "evaluate_risk":
+            # Signal to re-run the risk assessment and determine next flow
+            return TurnResult(
+                outcome=TurnOutcome.PROCEED,
+                message=f"Flow complete — re-evaluate ({exit_target})",
+                requires_reassessment=True,
+            )
+
+        # Resolve exit target as next flow
+        next_flow = self._resolver.resolve_next_flow(session, assessment, current_exit=exit_target)
+        if next_flow:
+            return self._enter_flow(session, next_flow)
+
+        return TurnResult(outcome=TurnOutcome.END, message="No next flow resolved")
+
+    def _get_current_flow(self, session: SessionState) -> Optional[FlowDefinition]:
+        """Get the current flow definition from session state."""
+        if not session.current_flow:
+            return None
+
+        # Check primitives first
+        prim = self._config.primitives.get(session.current_flow)
+        if prim:
+            return FlowDefinition.from_yaml(prim, source=f"primitives/{session.current_flow}")
+
+        # Check taxonomy flows
+        for domain, flows in self._config.taxonomy_flows.items():
+            if session.current_flow in flows:
+                return FlowDefinition.from_yaml(
+                    flows[session.current_flow],
+                    source=f"taxonomy/{domain}/{session.current_flow}",
+                )
+
+        return None
+
+
+# ---------------------------------------------------------------------------
+# Turn Result
+# ---------------------------------------------------------------------------
+
+class TurnResult:
+    """Result of processing a conversational turn."""
+
+    def __init__(
+        self,
+        outcome: TurnOutcome,
+        flow_id: Optional[str] = None,
+        flow_type: Optional[str] = None,
+        step_number: int = 0,
+        step_type: Optional[str] = None,
+        response_spec: Optional[ResponseSpecDef] = None,
+        collects: Optional[List[str]] = None,
+        handoff_target: Optional[str] = None,
+        handoff_urgency: Optional[str] = None,
+        risk_class: Optional[RiskClass] = None,
+        domain: Optional[str] = None,
+        message: str = "",
+        requires_reassessment: bool = False,
+    ):
+        self.outcome = outcome
+        self.flow_id = flow_id
+        self.flow_type = flow_type
+        self.step_number = step_number
+        self.step_type = step_type
+        self.response_spec = response_spec
+        self.collects = collects or []
+        self.handoff_target = handoff_target
+        self.handoff_urgency = handoff_urgency
+        self.risk_class = risk_class
+        self.domain = domain
+        self.message = message
+        self.requires_reassessment = requires_reassessment
+
+    @property
+    def is_escalation(self) -> bool:
+        return self.outcome == TurnOutcome.ESCALATE
+
+    @property
+    def is_handoff(self) -> bool:
+        return self.outcome in (TurnOutcome.ESCALATE, TurnOutcome.HANDOFF)
+
+    @property
+    def is_end(self) -> bool:
+        return self.outcome == TurnOutcome.END
+
+    @property
+    def prompt_constraints(self) -> Optional[str]:
+        """Get LLM prompt constraints from response spec."""
+        if self.response_spec:
+            return self.response_spec.to_prompt_constraints()
+        return None
+
+    def to_dict(self) -> Dict[str, Any]:
+        """Serialize for API response."""
+        result = {
+            "outcome": self.outcome.value,
+            "flow_id": self.flow_id,
+            "flow_type": self.flow_type,
+            "step_number": self.step_number,
+            "step_type": self.step_type,
+            "collects": self.collects,
+            "handoff_target": self.handoff_target,
+            "handoff_urgency": self.handoff_urgency,
+            "message": self.message,
+            "requires_reassessment": self.requires_reassessment,
+        }
+        if self.response_spec:
+            result["response_spec"] = {
+                "id": self.response_spec.spec_id,
+                "goal": self.response_spec.goal,
+                "tone": self.response_spec.tone,
+                "must_include": self.response_spec.must_include,
+                "must_ask": self.response_spec.must_ask,
+                "must_not": self.response_spec.must_not,
+                "max_questions": self.response_spec.max_questions,
+            }
+        if self.risk_class:
+            result["risk_class"] = self.risk_class.value
+        if self.domain:
+            result["domain"] = self.domain
+        return result
+
+    def __repr__(self) -> str:
+        return (
+            f"TurnResult(outcome={self.outcome.value}, flow={self.flow_id}, "
+            f"step={self.step_number}, type={self.step_type})"
+        )
diff --git a/decision/engine/journey_orchestrator.py b/decision/engine/journey_orchestrator.py
new file mode 100644
index 0000000000000000000000000000000000000000..825d4175f1fabaf27a16a815b056c2b9f588b92c
--- /dev/null
+++ b/decision/engine/journey_orchestrator.py
@@ -0,0 +1,478 @@
+"""
+Journey Orchestrator (Phase 3B).
+
+Manages multi-day patient engagement journeys with:
+  - Enrollment eligibility and deduplication
+  - Contact scheduling (offset days, time windows, channel selection)
+  - Contact caps (max per day/week, quiet hours)
+  - Wedge priority and conflict resolution
+  - Post-escalation suppression
+  - Journey step tracking and agenda management
+
+Usage:
+    orchestrator = JourneyOrchestrator(config, tenant_manager)
+    
+    # Enroll a patient
+    enrollment = orchestrator.enroll(patient_id, wedge_type, tenant_id, trigger_event_id)
+    
+    # Check if a contact is allowed right now
+    allowed, reason = orchestrator.can_contact(patient_id, channel="voice")
+    
+    # Get the next scheduled step
+    step = orchestrator.get_next_step(enrollment_id)
+"""
+
+from __future__ import annotations
+
+import logging
+from dataclasses import dataclass, field
+from datetime import datetime, timedelta, timezone
+from typing import Any, Dict, List, Optional, Set, Tuple
+
+from decision.engine.config_loader import DecisionConfigLoader
+from decision.engine.tenant_manager import TenantManager
+
+logger = logging.getLogger("decision.journey_orchestrator")
+
+
+# ---------------------------------------------------------------------------
+# Data models
+# ---------------------------------------------------------------------------
+
+@dataclass
+class Enrollment:
+    """A patient enrolled in a journey."""
+    enrollment_id: str
+    patient_id: str
+    wedge_type: str
+    tenant_id: str
+    trigger_event_id: str
+    status: str = "active"  # active, completed, withdrawn, paused
+    enrolled_at: datetime = field(default_factory=lambda: datetime.now(timezone.utc))
+    current_step: int = 0
+    completed_steps: List[int] = field(default_factory=list)
+    last_contact_at: Optional[datetime] = None
+    last_contact_channel: Optional[str] = None
+    next_scheduled_at: Optional[datetime] = None
+
+
+@dataclass
+class ContactRecord:
+    """Record of a patient contact for rate limiting."""
+    patient_id: str
+    channel: str  # voice, sms
+    timestamp: datetime
+    wedge_type: str
+    risk_class: Optional[str] = None
+
+
+@dataclass
+class JourneyStep:
+    """A step in a journey to be executed."""
+    step_index: int
+    step_name: str
+    channel: str
+    offset_days: int
+    window_start_hour: int
+    window_end_hour: int
+    agenda_sequence: List[str]
+    conditional_probes: List[Dict[str, Any]]
+    pre_populated_slots: List[str]
+
+
+@dataclass
+class ContactDecision:
+    """Result of a contact eligibility check."""
+    allowed: bool
+    reason: str
+    retry_after: Optional[datetime] = None
+
+
+# ---------------------------------------------------------------------------
+# Journey Orchestrator
+# ---------------------------------------------------------------------------
+
+class JourneyOrchestrator:
+    """
+    Orchestrates multi-day patient engagement journeys.
+    """
+
+    def __init__(
+        self,
+        config: DecisionConfigLoader,
+        tenant_manager: Optional[TenantManager] = None,
+    ):
+        self._config = config
+        self._tenant_manager = tenant_manager
+        self._journeys = config.journeys
+        self._orchestrator = config.orchestrator
+
+        # In-memory stores (production: replace with persistent storage)
+        self._enrollments: Dict[str, Enrollment] = {}  # enrollment_id -> Enrollment
+        self._patient_enrollments: Dict[str, List[str]] = {}  # patient_id -> [enrollment_ids]
+        self._contact_history: Dict[str, List[ContactRecord]] = {}  # patient_id -> [ContactRecord]
+
+        # Load orchestrator rules
+        self._contact_caps = self._orchestrator.get("contact_caps", {})
+        self._wedge_priority = self._orchestrator.get("wedge_priority", {})
+        self._conflict_rules = self._orchestrator.get("conflict_resolution", {})
+        self._enrollment_rules = self._orchestrator.get("enrollment_rules", {})
+        self._suppression_rules = self._orchestrator.get("wedge_suppression", {})
+
+        logger.info(
+            "JourneyOrchestrator initialized: %d journeys, %d wedge priorities",
+            len(self._journeys),
+            len(self._wedge_priority.get("priorities", [])),
+        )
+
+    # ------------------------------------------------------------------
+    # Enrollment
+    # ------------------------------------------------------------------
+
+    def enroll(
+        self,
+        patient_id: str,
+        wedge_type: str,
+        tenant_id: str,
+        trigger_event_id: str,
+    ) -> Tuple[Optional[Enrollment], str]:
+        """
+        Enroll a patient in a journey.
+
+        Returns:
+            (Enrollment, reason) — Enrollment object if successful, None if rejected.
+        """
+        # Check journey exists
+        if wedge_type not in self._journeys:
+            return None, f"Unknown wedge type: {wedge_type}"
+
+        # Check tenant enables this wedge
+        if self._tenant_manager:
+            if not self._tenant_manager.is_wedge_enabled(tenant_id, wedge_type):
+                return None, f"Wedge '{wedge_type}' not enabled for tenant '{tenant_id}'"
+
+        # Check deduplication
+        existing = self._patient_enrollments.get(patient_id, [])
+        for eid in existing:
+            enrollment = self._enrollments.get(eid)
+            if enrollment and enrollment.status == "active":
+                if enrollment.wedge_type == wedge_type and enrollment.trigger_event_id == trigger_event_id:
+                    return None, f"Duplicate enrollment: patient already in {wedge_type} for event {trigger_event_id}"
+
+        # Check max active enrollments
+        max_active = self._enrollment_rules.get("max_active_per_patient", 3)
+        active_count = sum(
+            1 for eid in existing
+            if self._enrollments.get(eid, Enrollment("", "", "", "", "")).status == "active"
+        )
+        if active_count >= max_active:
+            return None, f"Max active enrollments ({max_active}) reached for patient {patient_id}"
+
+        # Check cooldown
+        cooldown_days = self._get_cooldown(wedge_type)
+        if cooldown_days:
+            for eid in existing:
+                prev = self._enrollments.get(eid)
+                if prev and prev.wedge_type == wedge_type and prev.status == "completed":
+                    elapsed = (datetime.now(timezone.utc) - prev.enrolled_at).days
+                    if elapsed < cooldown_days:
+                        return None, f"Cooldown active: {cooldown_days - elapsed} days remaining for {wedge_type}"
+
+        # Create enrollment
+        import uuid
+        enrollment_id = f"enr-{uuid.uuid4().hex[:12]}"
+        enrollment = Enrollment(
+            enrollment_id=enrollment_id,
+            patient_id=patient_id,
+            wedge_type=wedge_type,
+            tenant_id=tenant_id,
+            trigger_event_id=trigger_event_id,
+        )
+
+        # Calculate first contact schedule
+        journey = self._journeys[wedge_type]
+        steps = journey.get("steps", [])
+        if steps:
+            first_step = steps[0]
+            offset = first_step.get("offset_days", 1)
+            enrollment.next_scheduled_at = datetime.now(timezone.utc) + timedelta(days=offset)
+
+        self._enrollments[enrollment_id] = enrollment
+        self._patient_enrollments.setdefault(patient_id, []).append(enrollment_id)
+
+        logger.info(
+            "Enrolled patient %s in %s (enrollment=%s, tenant=%s)",
+            patient_id, wedge_type, enrollment_id, tenant_id,
+        )
+        return enrollment, "enrolled"
+
+    # ------------------------------------------------------------------
+    # Contact eligibility
+    # ------------------------------------------------------------------
+
+    def can_contact(
+        self,
+        patient_id: str,
+        channel: str = "voice",
+        now: Optional[datetime] = None,
+    ) -> ContactDecision:
+        """
+        Check if a patient can be contacted right now.
+
+        Evaluates:
+          1. Quiet hours (default 9PM-9AM)
+          2. Channel-specific daily/weekly caps
+          3. Post-escalation suppression
+          4. Voice cooldown (4h between voice calls)
+        """
+        now = now or datetime.now(timezone.utc)
+
+        # 1. Quiet hours (YAML may store as "21:00" or 21)
+        raw_start = self._contact_caps.get("quiet_hours", {}).get("start", 21)
+        raw_end = self._contact_caps.get("quiet_hours", {}).get("end", 9)
+        quiet_start = int(str(raw_start).split(":")[0])
+        quiet_end = int(str(raw_end).split(":")[0])
+        current_hour = now.hour
+        if quiet_start <= current_hour or current_hour < quiet_end:
+            resume_at = now.replace(hour=quiet_end, minute=0, second=0, microsecond=0)
+            if current_hour >= quiet_start:
+                resume_at += timedelta(days=1)
+            return ContactDecision(
+                allowed=False,
+                reason=f"Quiet hours ({quiet_start}:00-{quiet_end}:00)",
+                retry_after=resume_at,
+            )
+
+        # 2. Daily/weekly caps
+        history = self._contact_history.get(patient_id, [])
+        today = now.date()
+        week_ago = now - timedelta(days=7)
+
+        daily_total = sum(1 for r in history if r.timestamp.date() == today)
+        weekly_total = sum(1 for r in history if r.timestamp >= week_ago)
+
+        max_daily = self._contact_caps.get("max_contacts_per_day", 2)
+        max_weekly = self._contact_caps.get("max_contacts_per_week", 7)
+
+        if daily_total >= max_daily:
+            tomorrow = now.replace(hour=quiet_end, minute=0) + timedelta(days=1)
+            return ContactDecision(
+                allowed=False,
+                reason=f"Daily contact cap reached ({daily_total}/{max_daily})",
+                retry_after=tomorrow,
+            )
+
+        if weekly_total >= max_weekly:
+            return ContactDecision(
+                allowed=False,
+                reason=f"Weekly contact cap reached ({weekly_total}/{max_weekly})",
+            )
+
+        # Channel-specific caps (stored as list of {channel, max_per_day, ...})
+        raw_channel_caps = self._contact_caps.get("channel_caps", [])
+        channel_caps = {}
+        if isinstance(raw_channel_caps, list):
+            for entry in raw_channel_caps:
+                if isinstance(entry, dict) and entry.get("channel") == channel:
+                    channel_caps = entry
+                    break
+        elif isinstance(raw_channel_caps, dict):
+            channel_caps = raw_channel_caps.get(channel, {})
+        ch_max_daily = channel_caps.get("max_per_day", max_daily)
+        ch_daily = sum(1 for r in history if r.timestamp.date() == today and r.channel == channel)
+        if ch_daily >= ch_max_daily:
+            return ContactDecision(
+                allowed=False,
+                reason=f"{channel} daily cap reached ({ch_daily}/{ch_max_daily})",
+            )
+
+        # 3. Post-escalation suppression
+        suppression_rules = self._suppression_rules.get("post_escalation", [])
+        for rule in suppression_rules:
+            risk_trigger = rule.get("after_risk_class")
+            suppress_hours = rule.get("suppress_all_hours", 0)
+            if risk_trigger and suppress_hours:
+                for record in reversed(history):
+                    if record.risk_class == risk_trigger:
+                        suppress_until = record.timestamp + timedelta(hours=suppress_hours)
+                        if now < suppress_until:
+                            return ContactDecision(
+                                allowed=False,
+                                reason=f"Post-{risk_trigger} suppression ({suppress_hours}h)",
+                                retry_after=suppress_until,
+                            )
+
+        # 4. Voice cooldown
+        if channel == "voice":
+            cooldown_hours = self._contact_caps.get("voice_cooldown_hours", 4)
+            voice_records = [r for r in history if r.channel == "voice"]
+            if voice_records:
+                last_voice = max(voice_records, key=lambda r: r.timestamp)
+                cooldown_until = last_voice.timestamp + timedelta(hours=cooldown_hours)
+                if now < cooldown_until:
+                    return ContactDecision(
+                        allowed=False,
+                        reason=f"Voice cooldown ({cooldown_hours}h since last voice contact)",
+                        retry_after=cooldown_until,
+                    )
+
+        return ContactDecision(allowed=True, reason="Contact allowed")
+
+    def record_contact(
+        self,
+        patient_id: str,
+        channel: str,
+        wedge_type: str,
+        risk_class: Optional[str] = None,
+    ) -> None:
+        """Record a contact for rate limiting."""
+        record = ContactRecord(
+            patient_id=patient_id,
+            channel=channel,
+            timestamp=datetime.now(timezone.utc),
+            wedge_type=wedge_type,
+            risk_class=risk_class,
+        )
+        self._contact_history.setdefault(patient_id, []).append(record)
+
+    # ------------------------------------------------------------------
+    # Journey step management
+    # ------------------------------------------------------------------
+
+    def get_next_step(self, enrollment_id: str) -> Optional[JourneyStep]:
+        """Get the next scheduled step for an enrollment."""
+        enrollment = self._enrollments.get(enrollment_id)
+        if not enrollment or enrollment.status != "active":
+            return None
+
+        journey = self._journeys.get(enrollment.wedge_type, {})
+        steps = journey.get("steps", [])
+
+        if enrollment.current_step >= len(steps):
+            return None
+
+        step_data = steps[enrollment.current_step]
+        return JourneyStep(
+            step_index=enrollment.current_step,
+            step_name=step_data.get("name", f"step_{enrollment.current_step}"),
+            channel=step_data.get("channel", "voice"),
+            offset_days=step_data.get("offset_days", 0),
+            window_start_hour=step_data.get("window_start_hour", 9),
+            window_end_hour=step_data.get("window_end_hour", 20),
+            agenda_sequence=step_data.get("agenda_sequence", []),
+            conditional_probes=step_data.get("conditional_probes", []),
+            pre_populated_slots=step_data.get("pre_populated_slots", []),
+        )
+
+    def advance_step(self, enrollment_id: str) -> bool:
+        """Mark the current step as completed and advance to next."""
+        enrollment = self._enrollments.get(enrollment_id)
+        if not enrollment or enrollment.status != "active":
+            return False
+
+        enrollment.completed_steps.append(enrollment.current_step)
+        enrollment.current_step += 1
+        enrollment.last_contact_at = datetime.now(timezone.utc)
+
+        journey = self._journeys.get(enrollment.wedge_type, {})
+        steps = journey.get("steps", [])
+
+        if enrollment.current_step >= len(steps):
+            enrollment.status = "completed"
+            logger.info("Enrollment %s completed all steps", enrollment_id)
+            return True
+
+        # Schedule next step
+        next_step = steps[enrollment.current_step]
+        offset = next_step.get("offset_days", 0)
+        enrollment.next_scheduled_at = datetime.now(timezone.utc) + timedelta(days=offset)
+
+        logger.info(
+            "Enrollment %s advanced to step %d (scheduled in %d days)",
+            enrollment_id, enrollment.current_step, offset,
+        )
+        return True
+
+    # ------------------------------------------------------------------
+    # Conflict resolution
+    # ------------------------------------------------------------------
+
+    def resolve_conflict(
+        self, patient_id: str
+    ) -> Optional[str]:
+        """
+        When multiple enrollments are due on the same day,
+        return the enrollment_id that should proceed (highest priority wins).
+        """
+        enrollment_ids = self._patient_enrollments.get(patient_id, [])
+        active = [
+            self._enrollments[eid]
+            for eid in enrollment_ids
+            if self._enrollments.get(eid, Enrollment("", "", "", "", "")).status == "active"
+        ]
+
+        if len(active) <= 1:
+            return active[0].enrollment_id if active else None
+
+        # Get priorities
+        priorities = {
+            p.get("wedge_type"): p.get("priority", 0)
+            for p in self._wedge_priority.get("priorities", [])
+        }
+
+        # Sort by priority descending
+        active.sort(key=lambda e: priorities.get(e.wedge_type, 0), reverse=True)
+
+        winner = active[0]
+        for loser in active[1:]:
+            if loser.next_scheduled_at and winner.next_scheduled_at:
+                if loser.next_scheduled_at.date() == winner.next_scheduled_at.date():
+                    # Defer loser by 24h
+                    loser.next_scheduled_at += timedelta(hours=24)
+                    logger.info(
+                        "Conflict resolution: %s (%s) wins over %s (%s), deferring 24h",
+                        winner.wedge_type, winner.enrollment_id,
+                        loser.wedge_type, loser.enrollment_id,
+                    )
+
+        return winner.enrollment_id
+
+    # ------------------------------------------------------------------
+    # Status and listing
+    # ------------------------------------------------------------------
+
+    def get_patient_enrollments(self, patient_id: str) -> List[Enrollment]:
+        """Get all enrollments for a patient."""
+        enrollment_ids = self._patient_enrollments.get(patient_id, [])
+        return [
+            self._enrollments[eid]
+            for eid in enrollment_ids
+            if eid in self._enrollments
+        ]
+
+    def get_enrollment(self, enrollment_id: str) -> Optional[Enrollment]:
+        return self._enrollments.get(enrollment_id)
+
+    def withdraw(self, enrollment_id: str, reason: str = "") -> bool:
+        enrollment = self._enrollments.get(enrollment_id)
+        if not enrollment:
+            return False
+        enrollment.status = "withdrawn"
+        logger.info("Enrollment %s withdrawn: %s", enrollment_id, reason)
+        return True
+
+    # ------------------------------------------------------------------
+    # Internal helpers
+    # ------------------------------------------------------------------
+
+    def _get_cooldown(self, wedge_type: str) -> Optional[int]:
+        """Get cooldown days for a wedge type."""
+        cooldowns = self._enrollment_rules.get("cooldown_days", {})
+        return cooldowns.get(wedge_type)
+
+    def _get_wedge_priority(self, wedge_type: str) -> int:
+        priorities = {
+            p.get("wedge_type"): p.get("priority", 0)
+            for p in self._wedge_priority.get("priorities", [])
+        }
+        return priorities.get(wedge_type, 0)
diff --git a/decision/engine/models.py b/decision/engine/models.py
new file mode 100644
index 0000000000000000000000000000000000000000..9beb7870bac9f3dda7ffbc95b850d9777f21fe19
--- /dev/null
+++ b/decision/engine/models.py
@@ -0,0 +1,322 @@
+"""
+Core data models for the Decision Engine.
+
+All models are immutable dataclasses to prevent accidental mutation
+during safety-critical evaluation pipelines.
+"""
+
+from __future__ import annotations
+
+import enum
+from dataclasses import dataclass, field
+from typing import Any, Dict, List, Optional
+
+
+# ---------------------------------------------------------------------------
+# Enums
+# ---------------------------------------------------------------------------
+
+class ConfidenceTier(enum.Enum):
+    """Confidence tier for taxonomy trigger matches."""
+    HIGH = "high"
+    MEDIUM = "medium"
+    LOW = "low"
+    NONE = "none"
+
+    def __ge__(self, other: ConfidenceTier) -> bool:
+        order = {self.HIGH: 3, self.MEDIUM: 2, self.LOW: 1, self.NONE: 0}
+        return order[self] >= order[other]
+
+    def __gt__(self, other: ConfidenceTier) -> bool:
+        order = {self.HIGH: 3, self.MEDIUM: 2, self.LOW: 1, self.NONE: 0}
+        return order[self] > order[other]
+
+    def __le__(self, other: ConfidenceTier) -> bool:
+        order = {self.HIGH: 3, self.MEDIUM: 2, self.LOW: 1, self.NONE: 0}
+        return order[self] <= order[other]
+
+    def __lt__(self, other: ConfidenceTier) -> bool:
+        order = {self.HIGH: 3, self.MEDIUM: 2, self.LOW: 1, self.NONE: 0}
+        return order[self] < order[other]
+
+
+class RiskClass(enum.Enum):
+    """Clinical risk classification tier."""
+    R0 = "R0"  # No clinical concern
+    R1 = "R1"  # Low-level concern, routine follow-up
+    R2 = "R2"  # Moderate concern, warm transfer to nurse
+    R3 = "R3"  # Emergent, instruct to call 911 + transfer
+
+    @property
+    def is_emergent(self) -> bool:
+        return self == RiskClass.R3
+
+    @property
+    def requires_nurse(self) -> bool:
+        return self in (RiskClass.R2, RiskClass.R3)
+
+    @property
+    def severity_rank(self) -> int:
+        return {self.R0: 0, self.R1: 1, self.R2: 2, self.R3: 3}[self]
+
+    def __ge__(self, other: RiskClass) -> bool:
+        return self.severity_rank >= other.severity_rank
+
+    def __gt__(self, other: RiskClass) -> bool:
+        return self.severity_rank > other.severity_rank
+
+    def __le__(self, other: RiskClass) -> bool:
+        return self.severity_rank <= other.severity_rank
+
+    def __lt__(self, other: RiskClass) -> bool:
+        return self.severity_rank < other.severity_rank
+
+
+class MatchType(enum.Enum):
+    """Type of lexical match that fired."""
+    PHRASE = "phrase"
+    REGEX = "regex"
+    PARTIAL = "partial"
+
+
+class NegationAction(enum.Enum):
+    """What to do when negation is detected."""
+    SUPPRESS = "suppress"              # Remove domain nomination entirely
+    DOWNGRADE_CONFIDENCE = "downgrade_confidence"  # Drop confidence one tier
+
+
+class TurnOutcome(enum.Enum):
+    """Possible outcomes after a conversational turn."""
+    PROCEED = "proceed"
+    CLARIFY = "clarify"
+    ESCALATE = "escalate"
+    HANDOFF = "handoff"
+    END = "end"
+
+
+class FlowType(enum.Enum):
+    """Type of conversation flow."""
+    SCREENING = "screening"
+    ESCALATION = "escalation"
+    CLARIFICATION = "clarification"
+    RESOLUTION = "resolution"
+    HANDOFF = "handoff"
+    PRIMITIVE = "primitive"
+
+
+class CallPhase(enum.Enum):
+    """Phase of the current call."""
+    SESSION_START = "session_start"
+    ACTIVE_CALL = "active_call"
+    ENDED = "ended"
+
+
+# ---------------------------------------------------------------------------
+# Trigger & Match Models
+# ---------------------------------------------------------------------------
+
+@dataclass(frozen=True)
+class TriggerMatch:
+    """A single lexical match from a taxonomy trigger."""
+    domain: str
+    confidence_tier: ConfidenceTier
+    match_type: MatchType
+    matched_text: str          # The phrase/pattern that matched
+    matched_span: str          # The actual text span from patient input
+    priority: int              # Domain priority from triggers.yaml
+
+
+@dataclass(frozen=True)
+class NegationResult:
+    """Result of negation analysis on a domain match."""
+    is_negated: bool
+    action: NegationAction
+    matched_pattern: str = ""  # Which negation pattern matched
+    original_confidence: ConfidenceTier = ConfidenceTier.NONE
+    adjusted_confidence: ConfidenceTier = ConfidenceTier.NONE
+
+
+@dataclass(frozen=True)
+class DomainNomination:
+    """A nominated clinical domain with combined confidence from ML + lexical signals."""
+    domain: str
+    display_name: str
+    confidence_tier: ConfidenceTier
+    priority: int                          # From triggers.yaml priority field
+    target_risk_class: Optional[RiskClass] # Default risk from rules.yaml
+    trigger_matches: tuple                 # Tuple of TriggerMatch (frozen)
+    negation_result: Optional[NegationResult] = None
+    ml_label: Optional[str] = None         # DriveHealthBERT predicted label
+    ml_confidence: Optional[float] = None  # DriveHealthBERT probability
+    recommended_flow: Optional[str] = None # From rules.yaml decision_rules
+
+    @property
+    def is_negated(self) -> bool:
+        return self.negation_result is not None and self.negation_result.is_negated
+
+    @property
+    def is_safety_critical(self) -> bool:
+        """R3 domains or hard-escalate domains."""
+        return self.target_risk_class == RiskClass.R3
+
+
+# ---------------------------------------------------------------------------
+# Risk Assessment Models
+# ---------------------------------------------------------------------------
+
+@dataclass(frozen=True)
+class RiskRuleMatch:
+    """A risk escalation rule that fired."""
+    rule_id: str
+    domain: str
+    risk_class: RiskClass
+    conditions_met: Dict[str, Any] = field(default_factory=dict)
+    context_conditions: Optional[Dict[str, Any]] = None
+
+
+@dataclass(frozen=True)
+class SuppressionResult:
+    """Result of domain suppression evaluation."""
+    suppressed: bool
+    suppressor_domain: Optional[str] = None
+    rule_reason: Optional[str] = None
+
+
+@dataclass(frozen=True)
+class RiskAssessment:
+    """Complete risk assessment for a patient utterance."""
+    # Primary result
+    risk_class: RiskClass
+    primary_domain: Optional[str]
+    # All nominated domains (ranked by priority)
+    domain_nominations: tuple           # Tuple of DomainNomination
+    # Which rules fired
+    matched_rules: tuple                # Tuple of RiskRuleMatch
+    # Suppression results
+    suppressions: tuple = ()            # Tuple of SuppressionResult
+    # Metadata
+    hard_escalate: bool = False         # suicidal_ideation / homicidal_ideation
+    safety_override: bool = False       # Lexical safety signal regardless of ML
+    ml_label: Optional[str] = None
+    ml_confidence: Optional[float] = None
+    recommended_flow: Optional[str] = None
+    recommended_action: Optional[TurnOutcome] = None
+
+    @property
+    def requires_911(self) -> bool:
+        return self.risk_class == RiskClass.R3
+
+    @property
+    def requires_nurse_transfer(self) -> bool:
+        return self.risk_class >= RiskClass.R2
+
+    def to_dict(self) -> Dict[str, Any]:
+        """Serialize for API response."""
+        return {
+            "risk_class": self.risk_class.value,
+            "primary_domain": self.primary_domain,
+            "requires_911": self.requires_911,
+            "requires_nurse_transfer": self.requires_nurse_transfer,
+            "hard_escalate": self.hard_escalate,
+            "safety_override": self.safety_override,
+            "ml_label": self.ml_label,
+            "ml_confidence": self.ml_confidence,
+            "recommended_flow": self.recommended_flow,
+            "recommended_action": self.recommended_action.value if self.recommended_action else None,
+            "domain_nominations": [
+                {
+                    "domain": n.domain,
+                    "confidence_tier": n.confidence_tier.value,
+                    "priority": n.priority,
+                    "target_risk_class": n.target_risk_class.value if n.target_risk_class else None,
+                    "is_negated": n.is_negated,
+                    "recommended_flow": n.recommended_flow,
+                    "trigger_match_count": len(n.trigger_matches),
+                }
+                for n in self.domain_nominations
+            ],
+            "matched_rules": [
+                {
+                    "rule_id": r.rule_id,
+                    "domain": r.domain,
+                    "risk_class": r.risk_class.value,
+                }
+                for r in self.matched_rules
+            ],
+        }
+
+
+# ---------------------------------------------------------------------------
+# Flow Execution Models (Phase 2 — stubs for forward compatibility)
+# ---------------------------------------------------------------------------
+
+@dataclass(frozen=True)
+class ResponseSpec:
+    """LLM response constraints for a flow step."""
+    spec_id: str
+    goal: str
+    tone: str
+    must_include: tuple = ()
+    must_ask: tuple = ()
+    must_not: tuple = ()
+    max_questions: int = 0
+
+
+@dataclass(frozen=True)
+class FlowStep:
+    """A single step in a conversation flow."""
+    step_number: int
+    step_type: str              # "ask", "respond", "handoff"
+    response_spec: ResponseSpec
+    collects: tuple = ()        # Slot names to extract
+    handoff_target: Optional[str] = None
+    handoff_urgency: Optional[str] = None
+
+
+@dataclass(frozen=True)
+class ConversationFlow:
+    """A complete conversation flow definition."""
+    flow_id: str
+    flow_type: FlowType
+    domain: Optional[str]
+    required_slots: tuple = ()
+    steps: tuple = ()           # Tuple of FlowStep
+    exit_rules: Dict[str, str] = field(default_factory=dict)
+
+
+# ---------------------------------------------------------------------------
+# Session State Models (Phase 2 — stubs for forward compatibility)
+# ---------------------------------------------------------------------------
+
+@dataclass
+class SlotState:
+    """Mutable slot tracker for an active conversation."""
+    slots: Dict[str, Any] = field(default_factory=dict)
+
+    def set_slot(self, name: str, value: Any) -> None:
+        self.slots[name] = value
+
+    def get_slot(self, name: str) -> Optional[Any]:
+        return self.slots.get(name)
+
+    def has_slot(self, name: str) -> bool:
+        return name in self.slots
+
+    def has_all(self, slot_names: List[str]) -> bool:
+        return all(name in self.slots for name in slot_names)
+
+
+@dataclass
+class SessionState:
+    """Mutable state for an active call session."""
+    session_id: str
+    patient_id: Optional[str] = None
+    tenant_id: Optional[str] = None
+    call_phase: CallPhase = CallPhase.SESSION_START
+    current_flow: Optional[str] = None
+    current_step: int = 0
+    agenda_position: int = 0
+    slots: SlotState = field(default_factory=SlotState)
+    domain_history: List[str] = field(default_factory=list)
+    risk_history: List[RiskAssessment] = field(default_factory=list)
+    turn_count: int = 0
diff --git a/decision/engine/risk_classifier.py b/decision/engine/risk_classifier.py
new file mode 100644
index 0000000000000000000000000000000000000000..84bca6a42a83238c08572a3ad5425cc9a05f8770
--- /dev/null
+++ b/decision/engine/risk_classifier.py
@@ -0,0 +1,456 @@
+"""
+Risk Classifier.
+
+Evaluates domain nominations against global risk escalation rules to
+produce a final RiskAssessment with R0/R1/R2/R3 classification.
+
+Evaluation pipeline:
+  1. Check hard-escalate domains (suicidal_ideation → always R3)
+  2. For each nominated domain, evaluate risk_escalation_rules
+  3. Apply domain suppression rules (R1 wound_concern suppresses R2 wound_infection)
+  4. Select highest risk class across all active nominations
+  5. Determine recommended action (proceed / clarify / escalate / handoff)
+
+Safety invariants:
+  - Hard-escalate domains CANNOT be suppressed
+  - R3 can never be downgraded by suppression
+  - When no rules match, default to the domain's target_risk_class
+  - When no target_risk_class exists, default to R1 (fail-open)
+  - Context-aware rules require explicit context; they fail closed (don't fire)
+    when context is unavailable
+"""
+
+from __future__ import annotations
+
+import logging
+from typing import Any, Dict, List, Optional, Set, Tuple
+
+from decision.engine.config_loader import DecisionConfigLoader
+from decision.engine.models import (
+    ConfidenceTier,
+    DomainNomination,
+    RiskAssessment,
+    RiskClass,
+    RiskRuleMatch,
+    SuppressionResult,
+    TurnOutcome,
+)
+
+logger = logging.getLogger("decision.risk_classifier")
+
+
+class RiskClassifier:
+    """
+    Classifies risk from domain nominations using global rules.
+
+    Usage:
+        classifier = RiskClassifier(config)
+        assessment = classifier.assess(
+            nominations=nominations,
+            slot_values={"shortness_of_breath": "yes"},
+            patient_context=None,  # Phase 3: FHIR data
+        )
+    """
+
+    def __init__(self, config: DecisionConfigLoader):
+        self._config = config
+        self._hard_escalate: Set[str] = config.hard_escalate_domains
+        self._safety_precedence: List[str] = config.safety_precedence
+        self._risk_rules: List[Dict[str, Any]] = config.risk_escalation_rules
+        self._suppression_rules: List[Dict[str, Any]] = config.domain_suppression_rules
+
+    def assess(
+        self,
+        nominations: List[DomainNomination],
+        slot_values: Optional[Dict[str, str]] = None,
+        patient_context: Optional[Dict[str, Any]] = None,
+        ml_label: Optional[str] = None,
+        ml_confidence: Optional[float] = None,
+    ) -> RiskAssessment:
+        """
+        Produce a complete risk assessment from domain nominations.
+
+        Args:
+            nominations: Ranked domain nominations from DomainNominator
+            slot_values: Currently filled slots (from flow execution)
+            patient_context: FHIR-derived patient context (Phase 3)
+            ml_label: Original DriveHealthBERT label
+            ml_confidence: Original DriveHealthBERT confidence
+
+        Returns:
+            RiskAssessment with final risk class, matched rules, etc.
+        """
+        if not nominations:
+            return self._empty_assessment(ml_label, ml_confidence)
+
+        slot_values = slot_values or {}
+        active_nominations = [n for n in nominations if not n.is_negated]
+
+        # Step 1: Check hard-escalate domains
+        hard_escalate = False
+        hard_domain = None
+        for nom in active_nominations:
+            if nom.domain in self._hard_escalate:
+                hard_escalate = True
+                hard_domain = nom.domain
+                logger.warning(
+                    "HARD ESCALATE triggered: domain=%s", nom.domain
+                )
+                break
+
+        # Step 2: Evaluate risk rules for each nomination
+        all_rule_matches: List[RiskRuleMatch] = []
+        for nom in active_nominations:
+            matches = self._evaluate_rules_for_domain(
+                nom.domain, slot_values, patient_context
+            )
+            all_rule_matches.extend(matches)
+
+        # Step 3: Apply domain suppression
+        suppressions: List[SuppressionResult] = []
+        suppressed_domains: Set[str] = set()
+        if not hard_escalate:
+            suppressions, suppressed_domains = self._evaluate_suppressions(
+                active_nominations
+            )
+
+        # Step 4: Determine highest risk class
+        risk_class = self._determine_risk_class(
+            nominations=active_nominations,
+            rule_matches=all_rule_matches,
+            suppressed_domains=suppressed_domains,
+            hard_escalate=hard_escalate,
+            hard_domain=hard_domain,
+        )
+
+        # Step 5: Determine primary domain
+        primary_domain = self._select_primary_domain(
+            active_nominations, suppressed_domains, hard_domain
+        )
+
+        # Step 6: Determine recommended action
+        recommended_action = self._determine_action(risk_class)
+
+        # Step 7: Determine recommended flow from primary domain
+        recommended_flow = None
+        for nom in active_nominations:
+            if nom.domain == primary_domain and nom.recommended_flow:
+                recommended_flow = nom.recommended_flow
+                break
+
+        # Safety override flag
+        safety_override = any(
+            nom.confidence_tier >= ConfidenceTier.HIGH
+            and nom.domain in set(self._safety_precedence)
+            and nom.domain not in suppressed_domains
+            for nom in active_nominations
+        )
+
+        return RiskAssessment(
+            risk_class=risk_class,
+            primary_domain=primary_domain,
+            domain_nominations=tuple(nominations),
+            matched_rules=tuple(all_rule_matches),
+            suppressions=tuple(suppressions),
+            hard_escalate=hard_escalate,
+            safety_override=safety_override,
+            ml_label=ml_label,
+            ml_confidence=ml_confidence,
+            recommended_flow=recommended_flow,
+            recommended_action=recommended_action,
+        )
+
+    # ------------------------------------------------------------------
+    # Internal evaluation
+    # ------------------------------------------------------------------
+
+    def _evaluate_rules_for_domain(
+        self,
+        domain: str,
+        slot_values: Dict[str, str],
+        patient_context: Optional[Dict[str, Any]],
+    ) -> List[RiskRuleMatch]:
+        """Evaluate all global risk rules for a specific domain."""
+        matches = []
+
+        for rule in self._risk_rules:
+            rule_id = rule.get("id", "unknown")
+            conditions = rule.get("if", {})
+            result = rule.get("then", {})
+
+            # Check domain match
+            rule_domain = conditions.get("domain")
+            if rule_domain != domain:
+                continue
+
+            # Check slot conditions
+            slots_present = conditions.get("slots_present", [])
+            slot_value_conditions = conditions.get("slot_values", {})
+            context_conditions = conditions.get("context")
+
+            # All required slots must be present
+            slots_ok = all(
+                slot_name in slot_values for slot_name in slots_present
+            )
+
+            # All slot value conditions must match
+            values_ok = all(
+                slot_values.get(k) == v
+                for k, v in slot_value_conditions.items()
+            )
+
+            # Context conditions (Phase 3)
+            context_ok = True
+            if context_conditions:
+                if patient_context is None:
+                    # Fail closed: context required but not available
+                    context_ok = False
+                else:
+                    context_ok = self._evaluate_context_conditions(
+                        context_conditions, patient_context
+                    )
+
+            if slots_ok and values_ok and context_ok:
+                risk_str = result.get("risk_class", "R1")
+                try:
+                    risk = RiskClass(risk_str)
+                except ValueError:
+                    risk = RiskClass.R1
+
+                matches.append(
+                    RiskRuleMatch(
+                        rule_id=rule_id,
+                        domain=domain,
+                        risk_class=risk,
+                        conditions_met=slot_value_conditions,
+                        context_conditions=context_conditions,
+                    )
+                )
+
+        return matches
+
+    def _evaluate_context_conditions(
+        self,
+        conditions: Dict[str, Any],
+        patient_context: Dict[str, Any],
+    ) -> bool:
+        """
+        Evaluate FHIR context conditions against patient context.
+
+        Phase 3: Full implementation. Currently supports:
+          - patient_has_condition: list of ICD-10 patterns
+          - medication_count_above: int threshold
+        """
+        # patient_has_condition: check ICD-10 codes
+        required_conditions = conditions.get("patient_has_condition", [])
+        if required_conditions:
+            patient_icd_codes = patient_context.get("active_conditions", [])
+            if not self._match_icd_patterns(required_conditions, patient_icd_codes):
+                return False
+
+        # medication_count_above: check polypharmacy
+        med_threshold = conditions.get("medication_count_above")
+        if med_threshold is not None:
+            med_count = patient_context.get("active_medication_count", 0)
+            if med_count <= med_threshold:
+                return False
+
+        return True
+
+    @staticmethod
+    def _match_icd_patterns(
+        patterns: List[str], patient_codes: List[str]
+    ) -> bool:
+        """Check if any patient ICD-10 code matches any required pattern."""
+        import re
+
+        for pattern in patterns:
+            # Convert ICD-10 wildcard to regex (e.g., "I50.*" → "I50\..*")
+            regex = pattern.replace(".", r"\.").replace("*", ".*")
+            for code in patient_codes:
+                if re.match(regex, code, re.IGNORECASE):
+                    return True
+        return False
+
+    def _evaluate_suppressions(
+        self, nominations: List[DomainNomination]
+    ) -> Tuple[List[SuppressionResult], Set[str]]:
+        """
+        Evaluate domain suppression rules.
+
+        A lower-acuity domain firing at high confidence can suppress
+        a higher-acuity domain at low/medium confidence to reduce
+        false escalations.
+        """
+        suppressions: List[SuppressionResult] = []
+        suppressed: Set[str] = set()
+
+        active_domains = {n.domain: n for n in nominations}
+
+        for rule in self._suppression_rules:
+            suppressor_name = rule.get("suppressor")
+            suppressed_list = rule.get("suppressed_domains", [])
+            condition = rule.get("condition", {})
+            reason = rule.get("reason", "")
+
+            suppressor = active_domains.get(suppressor_name)
+            if not suppressor:
+                continue
+
+            # Check suppressor minimum confidence
+            min_conf_str = condition.get("suppressor_min_confidence", "medium")
+            min_conf = self._str_to_confidence(min_conf_str)
+            if suppressor.confidence_tier < min_conf:
+                continue
+
+            # Check suppressed domains
+            max_conf_str = condition.get("suppressed_max_confidence", "medium")
+            max_conf = self._str_to_confidence(max_conf_str)
+
+            for target_name in suppressed_list:
+                target = active_domains.get(target_name)
+                if not target:
+                    continue
+
+                # SAFETY: Never suppress hard-escalate domains
+                if target_name in self._hard_escalate:
+                    continue
+
+                # Only suppress if target is at or below max confidence
+                if target.confidence_tier <= max_conf:
+                    suppressed.add(target_name)
+                    suppressions.append(
+                        SuppressionResult(
+                            suppressed=True,
+                            suppressor_domain=suppressor_name,
+                            rule_reason=reason,
+                        )
+                    )
+                    logger.info(
+                        "Domain suppression: %s suppresses %s (reason: %s)",
+                        suppressor_name,
+                        target_name,
+                        reason,
+                    )
+
+        return suppressions, suppressed
+
+    def _determine_risk_class(
+        self,
+        nominations: List[DomainNomination],
+        rule_matches: List[RiskRuleMatch],
+        suppressed_domains: Set[str],
+        hard_escalate: bool,
+        hard_domain: Optional[str],
+    ) -> RiskClass:
+        """Determine the highest applicable risk class."""
+
+        # Hard escalate always wins
+        if hard_escalate:
+            return RiskClass.R3
+
+        # Collect all risk classes from rule matches (excluding suppressed)
+        risk_candidates: List[RiskClass] = []
+        for rm in rule_matches:
+            if rm.domain not in suppressed_domains:
+                risk_candidates.append(rm.risk_class)
+
+        # ALSO consider target_risk_class from nominations (even when rules
+        # matched for other domains).  Previously this was a fallback that
+        # only ran when zero rules matched, which let a benign R1 rule on
+        # domain A mask a critical R3 target on domain B.
+        for nom in nominations:
+            if nom.domain in suppressed_domains:
+                continue
+            if nom.is_negated:
+                continue
+            if nom.target_risk_class:
+                # For high-confidence matches on safety domains, use target risk
+                if nom.confidence_tier >= ConfidenceTier.HIGH:
+                    risk_candidates.append(nom.target_risk_class)
+                elif nom.confidence_tier >= ConfidenceTier.MEDIUM:
+                    # Medium confidence: one tier below target, minimum R1
+                    downgraded = self._downgrade_risk(nom.target_risk_class)
+                    risk_candidates.append(downgraded)
+                else:
+                    # Low confidence: two tiers below or R1
+                    risk_candidates.append(RiskClass.R1)
+
+        if risk_candidates:
+            return max(risk_candidates)
+
+        # Absolute fallback: if we have any non-negated nomination, R1
+        if any(not n.is_negated for n in nominations):
+            return RiskClass.R1
+
+        return RiskClass.R0
+
+    def _select_primary_domain(
+        self,
+        nominations: List[DomainNomination],
+        suppressed_domains: Set[str],
+        hard_domain: Optional[str],
+    ) -> Optional[str]:
+        """Select the primary domain from active nominations."""
+        if hard_domain:
+            return hard_domain
+
+        # Use safety precedence order for tie-breaking
+        precedence_set = set(self._safety_precedence)
+
+        for nom in nominations:
+            if nom.domain in suppressed_domains:
+                continue
+            if nom.is_negated:
+                continue
+            return nom.domain  # Already sorted by confidence + priority
+
+        # All negated or suppressed
+        return nominations[0].domain if nominations else None
+
+    @staticmethod
+    def _determine_action(risk_class: RiskClass) -> TurnOutcome:
+        """Map risk class to recommended turn outcome."""
+        if risk_class == RiskClass.R3:
+            return TurnOutcome.ESCALATE
+        elif risk_class == RiskClass.R2:
+            return TurnOutcome.HANDOFF
+        elif risk_class == RiskClass.R1:
+            return TurnOutcome.PROCEED
+        return TurnOutcome.PROCEED
+
+    @staticmethod
+    def _downgrade_risk(risk: RiskClass) -> RiskClass:
+        """Downgrade risk by one tier, minimum R1."""
+        if risk == RiskClass.R3:
+            return RiskClass.R2
+        elif risk == RiskClass.R2:
+            return RiskClass.R1
+        return RiskClass.R1
+
+    @staticmethod
+    def _str_to_confidence(s: str) -> ConfidenceTier:
+        try:
+            return ConfidenceTier(s)
+        except ValueError:
+            return ConfidenceTier.MEDIUM
+
+    def _empty_assessment(
+        self,
+        ml_label: Optional[str] = None,
+        ml_confidence: Optional[float] = None,
+    ) -> RiskAssessment:
+        """Return a default R0 assessment when no nominations exist."""
+        return RiskAssessment(
+            risk_class=RiskClass.R0,
+            primary_domain=None,
+            domain_nominations=(),
+            matched_rules=(),
+            suppressions=(),
+            hard_escalate=False,
+            safety_override=False,
+            ml_label=ml_label,
+            ml_confidence=ml_confidence,
+            recommended_flow=None,
+            recommended_action=TurnOutcome.PROCEED,
+        )
diff --git a/decision/engine/tenant_manager.py b/decision/engine/tenant_manager.py
new file mode 100644
index 0000000000000000000000000000000000000000..f1a16ed3824aace3381147d3f79c9b38f6621587
--- /dev/null
+++ b/decision/engine/tenant_manager.py
@@ -0,0 +1,237 @@
+"""
+Multi-Tenant Configuration Manager (Phase 3B).
+
+Manages tenant-specific configuration overrides including:
+  - Enabled wedges and journeys per tenant
+  - Custom escalation rules (institution-specific clinical protocols)
+  - Domain overrides (enable/disable specific domains)
+  - Institution context (nurse line, ED name, timezone, branding)
+  - FHIR data source configuration
+  - Compliance settings (audit retention, PHI logging)
+
+Usage:
+    manager = TenantManager(config)
+    tenant = manager.get_tenant("example_health_system")
+    merged_rules = manager.get_merged_escalation_rules("example_health_system")
+    enabled_domains = manager.get_enabled_domains("example_health_system")
+"""
+
+from __future__ import annotations
+
+import logging
+from typing import Any, Dict, List, Optional, Set
+
+from decision.engine.config_loader import DecisionConfigLoader
+
+logger = logging.getLogger("decision.tenant_manager")
+
+
+class TenantConfig:
+    """Parsed tenant configuration with convenience accessors."""
+
+    def __init__(self, tenant_id: str, raw: Dict[str, Any]):
+        self.tenant_id = tenant_id
+        self._raw = raw
+
+    @property
+    def name(self) -> str:
+        return self._raw.get("institution_name", self.tenant_id)
+
+    @property
+    def type(self) -> str:
+        return self._raw.get("institution_type", "unknown")
+
+    @property
+    def enabled_wedges(self) -> List[str]:
+        return self._raw.get("enabled_wedges", [])
+
+    @property
+    def enabled_journeys(self) -> List[str]:
+        return self._raw.get("enabled_journeys", self.enabled_wedges)
+
+    @property
+    def custom_escalation_rules(self) -> List[Dict[str, Any]]:
+        return self._raw.get("custom_escalation_rules", [])
+
+    @property
+    def domain_overrides(self) -> Dict[str, Any]:
+        return self._raw.get("domain_overrides", {})
+
+    @property
+    def disabled_domains(self) -> Set[str]:
+        overrides = self.domain_overrides
+        return {
+            domain
+            for domain, cfg in overrides.items()
+            if isinstance(cfg, dict) and not cfg.get("enabled", True)
+        }
+
+    @property
+    def institution_context(self) -> Dict[str, Any]:
+        return self._raw.get("institution_context", {})
+
+    @property
+    def nurse_line_number(self) -> str:
+        return self.institution_context.get("nurse_line_number", "")
+
+    @property
+    def ed_name(self) -> str:
+        return self.institution_context.get("ed_name", "the emergency department")
+
+    @property
+    def timezone(self) -> str:
+        return self.institution_context.get("timezone", "America/New_York")
+
+    @property
+    def operating_hours(self) -> Dict[str, str]:
+        return self.institution_context.get("operating_hours", {})
+
+    @property
+    def fhir_config(self) -> Dict[str, Any]:
+        return self._raw.get("data_source", {}).get("fhir", {})
+
+    @property
+    def branding(self) -> Dict[str, str]:
+        return self._raw.get("branding", {})
+
+    @property
+    def greeting_name(self) -> str:
+        return self.branding.get("agent_introduction", "Avery, a care assistant")
+
+    @property
+    def compliance(self) -> Dict[str, Any]:
+        return self._raw.get("compliance", {})
+
+    @property
+    def audit_retention_years(self) -> int:
+        return self.compliance.get("audit_retention_years", 7)
+
+    def __repr__(self) -> str:
+        return f"TenantConfig({self.tenant_id}, name={self.name}, wedges={self.enabled_wedges})"
+
+
+class TenantManager:
+    """
+    Manages multi-tenant configurations and rule merging.
+
+    Provides:
+    - Tenant lookup and validation
+    - Merged escalation rules (global + tenant custom)
+    - Domain filtering (respect tenant disabled_domains)
+    - Institution context for response generation
+    """
+
+    def __init__(self, config: DecisionConfigLoader):
+        self._config = config
+        self._tenants: Dict[str, TenantConfig] = {}
+
+        for tid, raw in config.tenants.items():
+            self._tenants[tid] = TenantConfig(tid, raw)
+
+        logger.info("TenantManager initialized with %d tenants", len(self._tenants))
+
+    @property
+    def tenant_ids(self) -> List[str]:
+        return sorted(self._tenants.keys())
+
+    def get_tenant(self, tenant_id: str) -> Optional[TenantConfig]:
+        return self._tenants.get(tenant_id)
+
+    def get_merged_escalation_rules(
+        self, tenant_id: str
+    ) -> List[Dict[str, Any]]:
+        """
+        Merge global escalation rules with tenant-specific custom rules.
+
+        Tenant rules are appended AFTER global rules, so they take effect
+        as additional checks. Tenant rules with the same ID as global rules
+        override the global version.
+        """
+        global_rules = list(self._config.risk_escalation_rules)
+        tenant = self._tenants.get(tenant_id)
+        if not tenant:
+            return global_rules
+
+        custom = tenant.custom_escalation_rules
+        if not custom:
+            return global_rules
+
+        # Build a map of global rules by ID
+        global_ids = {r.get("id"): i for i, r in enumerate(global_rules)}
+
+        merged = list(global_rules)
+        for rule in custom:
+            rule_id = rule.get("id")
+            if rule_id and rule_id in global_ids:
+                # Override existing rule
+                merged[global_ids[rule_id]] = rule
+                logger.info(
+                    "Tenant %s overrides global rule: %s", tenant_id, rule_id
+                )
+            else:
+                # Append new rule
+                merged.append(rule)
+                logger.info(
+                    "Tenant %s adds custom rule: %s", tenant_id, rule_id
+                )
+
+        return merged
+
+    def get_enabled_domains(
+        self, tenant_id: str, all_domains: Optional[List[str]] = None
+    ) -> List[str]:
+        """
+        Get domains enabled for a tenant (all domains minus disabled ones).
+        """
+        if all_domains is None:
+            all_domains = self._config.domain_names
+
+        tenant = self._tenants.get(tenant_id)
+        if not tenant:
+            return all_domains
+
+        disabled = tenant.disabled_domains
+        if not disabled:
+            return all_domains
+
+        enabled = [d for d in all_domains if d not in disabled]
+        logger.info(
+            "Tenant %s: %d domains enabled (%d disabled: %s)",
+            tenant_id,
+            len(enabled),
+            len(disabled),
+            disabled,
+        )
+        return enabled
+
+    def is_wedge_enabled(self, tenant_id: str, wedge_type: str) -> bool:
+        """Check if a wedge/journey is enabled for a tenant."""
+        tenant = self._tenants.get(tenant_id)
+        if not tenant:
+            return True  # No tenant config = all enabled
+        return wedge_type in tenant.enabled_wedges
+
+    def get_institution_context_for_prompts(
+        self, tenant_id: str
+    ) -> Dict[str, str]:
+        """
+        Get institution-specific context for LLM prompt injection.
+
+        Returns strings that can be inserted into response specs.
+        """
+        tenant = self._tenants.get(tenant_id)
+        if not tenant:
+            return {
+                "agent_name": "Avery",
+                "institution_name": "your healthcare provider",
+                "nurse_line": "the nurse line",
+                "ed_name": "the emergency department",
+            }
+
+        return {
+            "agent_name": "Avery",
+            "institution_name": tenant.name,
+            "nurse_line": tenant.nurse_line_number or "the nurse line",
+            "ed_name": tenant.ed_name,
+            "greeting": tenant.greeting_name,
+        }
diff --git a/decision/engine/training_data_generator.py b/decision/engine/training_data_generator.py
new file mode 100644
index 0000000000000000000000000000000000000000..e98fa9372259190765a40105139ecf1dc8d4739c
--- /dev/null
+++ b/decision/engine/training_data_generator.py
@@ -0,0 +1,373 @@
+"""
+Training Data Generator (Phase 3C).
+
+Generates synthetic training samples from taxonomy trigger definitions
+for model retraining and augmentation.
+
+Each domain's triggers.yaml contains carefully curated phrases at
+multiple confidence tiers. These can be converted into labeled training
+examples to improve DriveHealthBERT's domain coverage.
+
+Capabilities:
+  - Generate ESCALATION samples from R2/R3 domain triggers
+  - Generate domain-specific samples with label mapping
+  - Generate negation examples (negative samples for safety)
+  - Template-based augmentation with variations
+  - JSONL output compatible with train.py
+
+Usage:
+    generator = TrainingDataGenerator(config)
+    samples = generator.generate_all()
+    generator.write_jsonl(samples, "data/taxonomy_augmented.jsonl")
+"""
+
+from __future__ import annotations
+
+import json
+import logging
+import random
+from pathlib import Path
+from typing import Any, Dict, List, Optional, Set, Tuple
+
+from decision.engine.config_loader import DecisionConfigLoader
+
+logger = logging.getLogger("decision.training_data_generator")
+
+# Map domains to DriveHealthBERT labels
+_DOMAIN_TO_LABEL = {
+    # R3 domains → ESCALATION
+    "chest_pain": "ESCALATION",
+    "suicidal_ideation": "ESCALATION",
+    "homicidal_ideation": "ESCALATION",
+    "stroke_symptoms": "ESCALATION",
+    "seizure": "ESCALATION",
+    "severe_bleeding": "ESCALATION",
+    "anaphylaxis": "ESCALATION",
+    "airway_compromise": "ESCALATION",
+    "overdose": "ESCALATION",
+    "pregnancy_emergency": "ESCALATION",
+    "ectopic_signal": "ESCALATION",
+    "febrile_neutropenia": "ESCALATION",
+    "meningitis_signal": "ESCALATION",
+    "dka_hhs": "ESCALATION",
+    "severe_hypoglycemia": "ESCALATION",
+    "syncope": "ESCALATION",
+    "thunderclap_headache": "ESCALATION",
+    "sudden_vision_loss": "ESCALATION",
+    "acute_limb_deficit": "ESCALATION",
+
+    # R2 domains → ESCALATION (moderate, but still escalation)
+    "shortness_of_breath_rest": "ESCALATION",
+    "palpitations_dizziness": "ESCALATION",
+    "heart_failure_worsening": "ESCALATION",
+    "gi_bleed": "ESCALATION",
+    "severe_abdominal_pain": "ESCALATION",
+    "wound_infection": "ESCALATION",
+    "fall_high_risk": "ESCALATION",
+    "behavioral_crisis": "ESCALATION",
+    "acute_confusion": "ESCALATION",
+    "persistent_vomiting": "ESCALATION",
+    "post_discharge_fever": "ESCALATION",
+    "dvt_signal": "ESCALATION",
+    "npo_violation": "ESCALATION",
+    "anticoagulant_hold_failure": "ESCALATION",
+    "acute_illness_preop": "ESCALATION",
+    "worsening_depression_si": "ESCALATION",
+    "procedure_anxiety_severe": "ESCALATION",
+    "domestic_safety_concern": "ESCALATION",
+
+    # R1/R0 symptom domains → SYMPTOM_CHECK
+    "exertional_dyspnea": "SYMPTOM_CHECK",
+    "persistent_dizziness": "SYMPTOM_CHECK",
+    "abnormal_bp": "SYMPTOM_CHECK",
+    "reproducible_chest_discomfort": "SYMPTOM_CHECK",
+    "wound_concern": "SYMPTOM_CHECK",
+    "uncontrolled_pain": "SYMPTOM_CHECK",
+    "worsening_chronic_pain": "SYMPTOM_CHECK",
+    "progressive_weakness": "SYMPTOM_CHECK",
+    "urinary_retention": "SYMPTOM_CHECK",
+    "severe_diarrhea": "SYMPTOM_CHECK",
+    "poor_oral_intake": "SYMPTOM_CHECK",
+    "new_jaundice": "SYMPTOM_CHECK",
+    "glucose_out_of_range": "SYMPTOM_CHECK",
+    "recurrent_falls": "SYMPTOM_CHECK",
+    "post_procedure_incontinence": "SYMPTOM_CHECK",
+
+    # Medication domains → MEDICATION
+    "medication": "MEDICATION",
+    "medication_nonadherence": "MEDICATION",
+
+    # Scheduling domains → APPOINTMENT
+    "scheduling": "APPOINTMENT",
+    "scheduling_barrier": "APPOINTMENT",
+    "missed_followup": "APPOINTMENT",
+    "post_discharge_engagement": "APPOINTMENT",
+
+    # Screening domains → SYMPTOM_CHECK
+    "phq2_positive": "SYMPTOM_CHECK",
+    "audit_c_positive": "SYMPTOM_CHECK",
+    "screening_gap_identified": "SYMPTOM_CHECK",
+    "screening_refusal": "GENERAL_INQUIRY",
+    "cognitive_concern": "SYMPTOM_CHECK",
+
+    # Social/safety domains
+    "caregiver_safety_concern": "ESCALATION",
+    "food_insecurity": "GENERAL_INQUIRY",
+    "social_isolation": "GENERAL_INQUIRY",
+    "tobacco_use_active": "GENERAL_INQUIRY",
+}
+
+# Templates for wrapping trigger phrases into natural sentences
+_PATIENT_TEMPLATES = [
+    "{phrase}",
+    "I have {phrase}",
+    "I'm experiencing {phrase}",
+    "I've been having {phrase}",
+    "I think I have {phrase}",
+    "My {phrase} is getting worse",
+    "I need help with {phrase}",
+    "I'm worried about {phrase}",
+    "I want to talk about {phrase}",
+    "Can you help me with {phrase}",
+]
+
+_NEGATION_TEMPLATES = [
+    "I don't have {phrase}",
+    "No {phrase}",
+    "I'm not experiencing {phrase}",
+    "{phrase} has gone away",
+    "I used to have {phrase} but not anymore",
+    "My mother had {phrase} not me",
+]
+
+
+class TrainingDataGenerator:
+    """Generates training data from taxonomy triggers."""
+
+    def __init__(self, config: DecisionConfigLoader):
+        self._config = config
+        self._triggers = config.taxonomy_triggers
+        self._rules = config.taxonomy_rules
+
+    def generate_all(
+        self,
+        include_negations: bool = True,
+        max_per_domain: int = 50,
+        augment_templates: bool = True,
+        seed: int = 42,
+    ) -> List[Dict[str, str]]:
+        """
+        Generate training samples from all taxonomy domains.
+
+        Args:
+            include_negations: Also generate negative samples from negation patterns
+            max_per_domain: Maximum samples per domain
+            augment_templates: Apply template-based augmentation
+            seed: Random seed for reproducibility
+
+        Returns:
+            List of {"text": ..., "label": ..., "source": ...} dicts
+        """
+        random.seed(seed)
+        all_samples: List[Dict[str, str]] = []
+
+        for domain_name, triggers in self._triggers.items():
+            label = _DOMAIN_TO_LABEL.get(domain_name)
+            if not label:
+                logger.debug("Skipping domain %s (no label mapping)", domain_name)
+                continue
+
+            domain_samples = self._generate_for_domain(
+                domain_name, triggers, label, augment_templates, max_per_domain
+            )
+            all_samples.extend(domain_samples)
+
+            # Generate negation samples
+            if include_negations and label == "ESCALATION":
+                neg_samples = self._generate_negations(
+                    domain_name, triggers, max_per_domain // 3
+                )
+                all_samples.extend(neg_samples)
+
+        random.shuffle(all_samples)
+
+        # Summary
+        label_counts = {}
+        for s in all_samples:
+            label_counts[s["label"]] = label_counts.get(s["label"], 0) + 1
+
+        logger.info(
+            "Generated %d training samples from %d domains: %s",
+            len(all_samples),
+            len(self._triggers),
+            label_counts,
+        )
+
+        return all_samples
+
+    def _generate_for_domain(
+        self,
+        domain_name: str,
+        triggers: Dict[str, Any],
+        label: str,
+        augment: bool,
+        max_samples: int,
+    ) -> List[Dict[str, str]]:
+        """Generate training samples for a single domain."""
+        samples = []
+        lexical = triggers.get("lexical_signals", {})
+
+        for tier_name in ("high", "medium", "low"):
+            tier = lexical.get(tier_name, {})
+
+            # Direct phrase samples
+            for phrase in tier.get("phrases", []):
+                samples.append({
+                    "text": phrase,
+                    "label": label,
+                    "source": f"taxonomy/{domain_name}/{tier_name}/phrase",
+                })
+
+                # Template augmentation
+                if augment:
+                    templates = random.sample(
+                        _PATIENT_TEMPLATES, min(3, len(_PATIENT_TEMPLATES))
+                    )
+                    for template in templates:
+                        try:
+                            augmented = template.format(phrase=phrase.lower())
+                            if augmented != phrase:
+                                samples.append({
+                                    "text": augmented,
+                                    "label": label,
+                                    "source": f"taxonomy/{domain_name}/{tier_name}/augmented",
+                                })
+                        except (KeyError, IndexError):
+                            pass
+
+            # Partial samples (lower confidence)
+            for partial in tier.get("partials", []):
+                samples.append({
+                    "text": partial,
+                    "label": label,
+                    "source": f"taxonomy/{domain_name}/{tier_name}/partial",
+                })
+
+        # Deduplicate by text
+        seen = set()
+        unique = []
+        for s in samples:
+            text_lower = s["text"].lower().strip()
+            if text_lower not in seen:
+                seen.add(text_lower)
+                unique.append(s)
+
+        # Cap per domain
+        if len(unique) > max_samples:
+            unique = random.sample(unique, max_samples)
+
+        return unique
+
+    def _generate_negations(
+        self,
+        domain_name: str,
+        triggers: Dict[str, Any],
+        max_samples: int,
+    ) -> List[Dict[str, str]]:
+        """
+        Generate negative samples from negation patterns.
+
+        These become NON-ESCALATION training examples to reduce false positives.
+        """
+        samples = []
+        negation = triggers.get("negation_handling", {})
+        patterns = negation.get("patterns", [])
+
+        # Use negation patterns directly as negative examples
+        for pattern in patterns:
+            samples.append({
+                "text": pattern,
+                "label": "GENERAL_INQUIRY",  # Negated safety = not escalation
+                "source": f"taxonomy/{domain_name}/negation",
+            })
+
+        # Apply negation templates to domain phrases
+        lexical = triggers.get("lexical_signals", {})
+        high_phrases = lexical.get("high", {}).get("phrases", [])
+
+        for phrase in high_phrases[:5]:  # Top 5 high-confidence phrases
+            templates = random.sample(
+                _NEGATION_TEMPLATES, min(2, len(_NEGATION_TEMPLATES))
+            )
+            for template in templates:
+                try:
+                    negated = template.format(phrase=phrase.lower())
+                    samples.append({
+                        "text": negated,
+                        "label": "GENERAL_INQUIRY",
+                        "source": f"taxonomy/{domain_name}/negation_augmented",
+                    })
+                except (KeyError, IndexError):
+                    pass
+
+        if len(samples) > max_samples:
+            samples = random.sample(samples, max_samples)
+
+        return samples
+
+    def write_jsonl(
+        self, samples: List[Dict[str, str]], output_path: str
+    ) -> int:
+        """Write samples to JSONL file compatible with train.py."""
+        path = Path(output_path)
+        path.parent.mkdir(parents=True, exist_ok=True)
+
+        count = 0
+        with open(path, "w", encoding="utf-8") as f:
+            for sample in samples:
+                record = {
+                    "text": sample["text"],
+                    "label": sample["label"],
+                }
+                f.write(json.dumps(record, ensure_ascii=False) + "\n")
+                count += 1
+
+        logger.info("Wrote %d samples to %s", count, path)
+        return count
+
+    def get_label_distribution(
+        self, samples: List[Dict[str, str]]
+    ) -> Dict[str, int]:
+        """Get label distribution of generated samples."""
+        dist: Dict[str, int] = {}
+        for s in samples:
+            dist[s["label"]] = dist.get(s["label"], 0) + 1
+        return dict(sorted(dist.items(), key=lambda x: x[1], reverse=True))
+
+    def get_domain_coverage_report(
+        self, samples: List[Dict[str, str]]
+    ) -> str:
+        """Generate a coverage report."""
+        domain_count: Dict[str, int] = {}
+        for s in samples:
+            source = s.get("source", "")
+            domain = source.split("/")[1] if "/" in source else "unknown"
+            domain_count[domain] = domain_count.get(domain, 0) + 1
+
+        lines = ["=== Training Data Coverage Report ===", ""]
+        lines.append(f"Total samples: {len(samples)}")
+        lines.append(f"Domains covered: {len(domain_count)}")
+        lines.append("")
+
+        dist = self.get_label_distribution(samples)
+        lines.append("Label distribution:")
+        for label, count in dist.items():
+            pct = count / len(samples) * 100
+            lines.append(f"  {label:20s}: {count:5d} ({pct:.1f}%)")
+
+        lines.append("")
+        lines.append("Top domains by sample count:")
+        for domain, count in sorted(domain_count.items(), key=lambda x: x[1], reverse=True)[:15]:
+            lines.append(f"  {domain:35s}: {count:4d}")
+
+        return "\n".join(lines)
diff --git a/decision/engine/trigger_engine.py b/decision/engine/trigger_engine.py
new file mode 100644
index 0000000000000000000000000000000000000000..98296dc6bfd977c3e6e2d37e8fb88b6c73cf4f32
--- /dev/null
+++ b/decision/engine/trigger_engine.py
@@ -0,0 +1,323 @@
+"""
+Taxonomy Trigger Engine.
+
+Matches patient utterances against all 65 clinical domain trigger definitions
+using phrase matching, regex patterns, partial substring matching, and
+negation handling.
+
+Safety-critical: This is the last line of defense for catching clinical
+emergencies that the ML model may miss. False negatives here can be
+life-threatening.
+
+Design principles:
+  - Fail open: If in doubt, nominate the domain (better to over-escalate)
+  - Exhaustive matching: Check ALL domains, not just the first match
+  - Negation requires explicit evidence: Only suppress if negation pattern
+    clearly matches
+  - Pre-compiled regex: All patterns compiled at config load time
+  - Case-insensitive matching throughout
+"""
+
+from __future__ import annotations
+
+import logging
+import re
+from typing import Any, Dict, List, Optional, Set, Tuple
+
+from decision.engine.config_loader import DecisionConfigLoader
+from decision.engine.models import (
+    ConfidenceTier,
+    MatchType,
+    NegationAction,
+    NegationResult,
+    TriggerMatch,
+)
+
+logger = logging.getLogger("decision.trigger_engine")
+
+
+class TaxonomyTriggerEngine:
+    """
+    Matches text against taxonomy trigger definitions.
+
+    Usage:
+        engine = TaxonomyTriggerEngine(config)
+        matches = engine.match_all(text)
+        # Returns: Dict[str, DomainMatchResult] keyed by domain name
+    """
+
+    def __init__(self, config: DecisionConfigLoader):
+        self._config = config
+        self._domains: Dict[str, Dict[str, Any]] = config.taxonomy_triggers
+        logger.info(
+            "TaxonomyTriggerEngine initialized with %d domains", len(self._domains)
+        )
+
+    # ------------------------------------------------------------------
+    # Public API
+    # ------------------------------------------------------------------
+
+    def match_all(self, text: str) -> Dict[str, DomainMatchResult]:
+        """
+        Match text against ALL taxonomy domains.
+
+        Returns a dict of domain_name -> DomainMatchResult for every domain
+        that has at least one trigger match (before negation).
+
+        Negation is evaluated but does NOT remove the domain from results.
+        The caller decides what to do based on negation_result.
+        """
+        text_lower = text.lower().strip()
+        if not text_lower:
+            return {}
+
+        results: Dict[str, DomainMatchResult] = {}
+
+        for domain_name, triggers in self._domains.items():
+            result = self._match_domain(domain_name, triggers, text, text_lower)
+            if result and result.highest_confidence != ConfidenceTier.NONE:
+                results[domain_name] = result
+
+        return results
+
+    def match_domain(self, domain_name: str, text: str) -> Optional[DomainMatchResult]:
+        """Match text against a single domain's triggers."""
+        triggers = self._domains.get(domain_name)
+        if not triggers:
+            return None
+        text_lower = text.lower().strip()
+        return self._match_domain(domain_name, triggers, text, text_lower)
+
+    def check_negation(
+        self, domain_name: str, text: str
+    ) -> NegationResult:
+        """Check if text matches negation patterns for a domain."""
+        triggers = self._domains.get(domain_name, {})
+        text_lower = text.lower().strip()
+        return self._evaluate_negation(domain_name, triggers, text_lower)
+
+    # ------------------------------------------------------------------
+    # Internal matching
+    # ------------------------------------------------------------------
+
+    def _match_domain(
+        self,
+        domain_name: str,
+        triggers: Dict[str, Any],
+        text: str,
+        text_lower: str,
+    ) -> Optional[DomainMatchResult]:
+        """Match text against a single domain's trigger definition."""
+        lexical = triggers.get("lexical_signals", {})
+        priority = triggers.get("priority", 0)
+
+        all_matches: List[TriggerMatch] = []
+
+        # Check each confidence tier (high → medium → low)
+        for tier_name, tier_enum in [
+            ("high", ConfidenceTier.HIGH),
+            ("medium", ConfidenceTier.MEDIUM),
+            ("low", ConfidenceTier.LOW),
+        ]:
+            tier = lexical.get(tier_name, {})
+            tier_matches = self._match_tier(
+                domain_name, tier, tier_enum, text, text_lower, priority
+            )
+            all_matches.extend(tier_matches)
+
+        if not all_matches:
+            return None
+
+        # Determine highest confidence from matches
+        highest = ConfidenceTier.NONE
+        for m in all_matches:
+            if m.confidence_tier > highest:
+                highest = m.confidence_tier
+
+        # Evaluate negation
+        negation = self._evaluate_negation(domain_name, triggers, text_lower)
+
+        # Apply negation to adjust confidence
+        effective_confidence = highest
+        if negation.is_negated:
+            if negation.action == NegationAction.SUPPRESS:
+                effective_confidence = ConfidenceTier.NONE
+            elif negation.action == NegationAction.DOWNGRADE_CONFIDENCE:
+                effective_confidence = self._downgrade_tier(highest)
+
+        return DomainMatchResult(
+            domain=domain_name,
+            priority=priority,
+            matches=tuple(all_matches),
+            highest_confidence=highest,
+            effective_confidence=effective_confidence,
+            negation_result=negation,
+        )
+
+    def _match_tier(
+        self,
+        domain_name: str,
+        tier: Dict[str, Any],
+        tier_enum: ConfidenceTier,
+        text: str,
+        text_lower: str,
+        priority: int,
+    ) -> List[TriggerMatch]:
+        """Match text against a single confidence tier."""
+        matches: List[TriggerMatch] = []
+
+        # 1. Phrase matching (exact substring, case-insensitive)
+        for phrase in tier.get("phrases", []):
+            phrase_lower = phrase.lower()
+            idx = text_lower.find(phrase_lower)
+            if idx >= 0:
+                matched_span = text[idx : idx + len(phrase)]
+                matches.append(
+                    TriggerMatch(
+                        domain=domain_name,
+                        confidence_tier=tier_enum,
+                        match_type=MatchType.PHRASE,
+                        matched_text=phrase,
+                        matched_span=matched_span,
+                        priority=priority,
+                    )
+                )
+
+        # 2. Regex matching (pre-compiled)
+        for compiled_re in tier.get("_compiled_regex", []):
+            m = compiled_re.search(text)
+            if m:
+                matches.append(
+                    TriggerMatch(
+                        domain=domain_name,
+                        confidence_tier=tier_enum,
+                        match_type=MatchType.REGEX,
+                        matched_text=compiled_re.pattern,
+                        matched_span=m.group(0),
+                        priority=priority,
+                    )
+                )
+
+        # 3. Partial matching (substring, case-insensitive)
+        for partial in tier.get("partials", []):
+            partial_lower = partial.lower()
+            idx = text_lower.find(partial_lower)
+            if idx >= 0:
+                matched_span = text[idx : idx + len(partial)]
+                matches.append(
+                    TriggerMatch(
+                        domain=domain_name,
+                        confidence_tier=tier_enum,
+                        match_type=MatchType.PARTIAL,
+                        matched_text=partial,
+                        matched_span=matched_span,
+                        priority=priority,
+                    )
+                )
+
+        return matches
+
+    def _evaluate_negation(
+        self,
+        domain_name: str,
+        triggers: Dict[str, Any],
+        text_lower: str,
+    ) -> NegationResult:
+        """
+        Evaluate negation patterns for a domain.
+
+        SAFETY DESIGN: Negation requires an EXPLICIT match against a known
+        negation pattern. We do NOT use generic "no/not" detection because
+        that risks suppressing true emergencies.
+        """
+        negation_config = triggers.get("negation_handling", {})
+        compiled_patterns: List[str] = negation_config.get("_compiled_patterns", [])
+        action_str = negation_config.get("action", "downgrade_confidence")
+
+        try:
+            action = NegationAction(action_str)
+        except ValueError:
+            action = NegationAction.DOWNGRADE_CONFIDENCE
+
+        for pattern in compiled_patterns:
+            if pattern in text_lower:
+                return NegationResult(
+                    is_negated=True,
+                    action=action,
+                    matched_pattern=pattern,
+                )
+
+        return NegationResult(
+            is_negated=False,
+            action=action,
+        )
+
+    @staticmethod
+    def _downgrade_tier(tier: ConfidenceTier) -> ConfidenceTier:
+        """Downgrade confidence by one level."""
+        if tier == ConfidenceTier.HIGH:
+            return ConfidenceTier.MEDIUM
+        elif tier == ConfidenceTier.MEDIUM:
+            return ConfidenceTier.LOW
+        elif tier == ConfidenceTier.LOW:
+            return ConfidenceTier.NONE
+        return ConfidenceTier.NONE
+
+
+# ---------------------------------------------------------------------------
+# Domain Match Result
+# ---------------------------------------------------------------------------
+
+class DomainMatchResult:
+    """
+    Result of matching a single domain against patient text.
+
+    Contains all trigger matches, the highest raw confidence,
+    effective confidence (after negation), and negation details.
+    """
+
+    __slots__ = (
+        "domain",
+        "priority",
+        "matches",
+        "highest_confidence",
+        "effective_confidence",
+        "negation_result",
+    )
+
+    def __init__(
+        self,
+        domain: str,
+        priority: int,
+        matches: Tuple[TriggerMatch, ...],
+        highest_confidence: ConfidenceTier,
+        effective_confidence: ConfidenceTier,
+        negation_result: NegationResult,
+    ):
+        self.domain = domain
+        self.priority = priority
+        self.matches = matches
+        self.highest_confidence = highest_confidence
+        self.effective_confidence = effective_confidence
+        self.negation_result = negation_result
+
+    @property
+    def is_negated(self) -> bool:
+        return self.negation_result.is_negated
+
+    @property
+    def is_suppressed(self) -> bool:
+        return self.effective_confidence == ConfidenceTier.NONE
+
+    @property
+    def match_count(self) -> int:
+        return len(self.matches)
+
+    def __repr__(self) -> str:
+        neg = " [NEGATED]" if self.is_negated else ""
+        return (
+            f"DomainMatchResult({self.domain}, "
+            f"confidence={self.effective_confidence.value}, "
+            f"priority={self.priority}, "
+            f"matches={self.match_count}{neg})"
+        )
diff --git a/decision/global/global_rules.yaml b/decision/global/global_rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..edb44edb5776051e80edf0ca204d2f66ac2f27b4
--- /dev/null
+++ b/decision/global/global_rules.yaml
@@ -0,0 +1,666 @@
+safety_precedence:
+  # R3 domains ordered by clinical acuity
+  - chest_pain
+  - airway_compromise
+  - shortness_of_breath_rest
+  - exertional_dyspnea
+  - severe_bleeding
+  - gi_bleed
+  - stroke_symptoms
+  - acute_limb_deficit
+  - syncope
+  - anaphylaxis
+  - seizure
+  - suicidal_ideation
+  - homicidal_ideation
+  - overdose
+  - thunderclap_headache
+  - pregnancy_emergency
+  - severe_hypoglycemia
+  - dka_hhs
+  - febrile_neutropenia
+  - sudden_vision_loss
+  # R2 safety domain — domestic violence / elder abuse
+  - domestic_safety_concern
+
+call_phases:
+  - session_start
+  - active_call
+  - ended
+
+primitive_sequence:
+  - greeting
+  - identity_verify
+  - consent
+
+fallback_flow: primitives/clarify
+
+risk_classes:
+  R0: "No clinical concern identified"
+  R1: "Low-level concern, routine follow-up"
+  R2: "Moderate concern, warm transfer to nurse"
+  R3: "Emergent, instruct patient to call 911 and transfer to nurse"
+
+risk_escalation_rules:
+  - id: chest_pain_with_sob
+    if:
+      domain: chest_pain
+      slots_present:
+        - shortness_of_breath
+      slot_values:
+        shortness_of_breath: "yes"
+    then:
+      risk_class: R3
+
+  - id: chest_pain_with_syncope
+    if:
+      domain: chest_pain
+      slots_present:
+        - syncope_or_dizziness
+      slot_values:
+        syncope_or_dizziness: "yes"
+    then:
+      risk_class: R3
+
+  - id: chest_pain_isolated
+    if:
+      domain: chest_pain
+      slots_present:
+        - chest_pain_severity
+    then:
+      risk_class: R3
+
+  - id: chest_pain_screening_clear
+    if:
+      domain: chest_pain
+      slot_values:
+        shortness_of_breath: "no"
+        syncope_or_dizziness: "no"
+    then:
+      risk_class: R3
+
+  # ── DKA/HHS ──────────────────────────────────────────────────
+  - id: dka_hhs_confirmed_nausea
+    if:
+      domain: dka_hhs
+      slots_present:
+        - nausea_vomiting
+      slot_values:
+        nausea_vomiting: "yes"
+    then:
+      risk_class: R3
+
+  - id: dka_hhs_confirmed_confusion
+    if:
+      domain: dka_hhs
+      slots_present:
+        - confusion_status
+      slot_values:
+        confusion_status: "yes"
+    then:
+      risk_class: R3
+
+  - id: dka_hhs_glucose_critical
+    if:
+      domain: dka_hhs
+      slots_present:
+        - glucose_level_bucket
+      slot_values:
+        glucose_level_bucket: "severe"
+    then:
+      risk_class: R3
+
+  - id: dka_hhs_glucose_high
+    if:
+      domain: dka_hhs
+      slots_present:
+        - glucose_level_bucket
+      slot_values:
+        glucose_level_bucket: "moderate"
+    then:
+      risk_class: R2
+
+  - id: dka_hhs_screening_clear
+    if:
+      domain: dka_hhs
+      slot_values:
+        nausea_vomiting: "no"
+        confusion_status: "no"
+    then:
+      risk_class: R2
+
+  # ── Shortness of Breath at Rest ──────────────────────────────
+  - id: sob_rest_confirmed
+    if:
+      domain: shortness_of_breath_rest
+      slots_present:
+        - sob_at_rest
+      slot_values:
+        sob_at_rest: "yes"
+    then:
+      risk_class: R3
+
+  - id: sob_rest_exertion_only
+    if:
+      domain: shortness_of_breath_rest
+      slot_values:
+        sob_at_rest: "no"
+    then:
+      risk_class: R0
+
+  # ── Wound Infection ──────────────────────────────────────────
+  - id: wound_infection_confirmed_fever
+    if:
+      domain: wound_infection
+      slots_present:
+        - fever_present
+      slot_values:
+        fever_present: "yes"
+    then:
+      risk_class: R3
+
+  - id: wound_infection_confirmed_systemic
+    if:
+      domain: wound_infection
+      slots_present:
+        - wound_systemic_signs
+      slot_values:
+        wound_systemic_signs: "yes"
+    then:
+      risk_class: R3
+
+  - id: wound_infection_screening_clear
+    if:
+      domain: wound_infection
+      slot_values:
+        fever_present: "no"
+        wound_systemic_signs: "no"
+    then:
+      risk_class: R2
+
+  # ── DVT Signal ───────────────────────────────────────────────
+  - id: dvt_signal_confirmed_swelling
+    if:
+      domain: dvt_signal
+      slots_present:
+        - leg_swelling_acute
+      slot_values:
+        leg_swelling_acute: "yes"
+    then:
+      risk_class: R2
+
+  - id: dvt_signal_confirmed_tenderness
+    if:
+      domain: dvt_signal
+      slots_present:
+        - calf_tenderness
+      slot_values:
+        calf_tenderness: "yes"
+    then:
+      risk_class: R2
+
+  - id: dvt_signal_screening_clear
+    if:
+      domain: dvt_signal
+      slot_values:
+        leg_swelling_acute: "no"
+        calf_tenderness: "no"
+    then:
+      risk_class: R0
+
+  # ── Fall High Risk ──────────────────────────────────────────
+  - id: fall_confirmed_loc
+    if:
+      domain: fall_high_risk
+      slot_values:
+        loss_of_consciousness: "yes"
+    then:
+      risk_class: R3
+
+  - id: fall_confirmed_head_strike_anticoag
+    if:
+      domain: fall_high_risk
+      slot_values:
+        head_strike: "yes"
+        on_anticoagulant: "yes"
+    then:
+      risk_class: R3
+
+  - id: fall_confirmed_head_strike
+    if:
+      domain: fall_high_risk
+      slots_present:
+        - head_strike
+      slot_values:
+        head_strike: "yes"
+    then:
+      risk_class: R2
+
+  - id: fall_confirmed_anticoagulant
+    if:
+      domain: fall_high_risk
+      slots_present:
+        - on_anticoagulant
+      slot_values:
+        on_anticoagulant: "yes"
+    then:
+      risk_class: R2
+
+  - id: fall_screening_clear
+    if:
+      domain: fall_high_risk
+      slot_values:
+        head_strike: "no"
+        injury_present: "no"
+    then:
+      risk_class: R0
+
+  # ── Anaphylaxis ─────────────────────────────────────────────
+  - id: anaphylaxis_confirmed_swelling
+    if:
+      domain: anaphylaxis
+      slots_present:
+        - tongue_lip_swelling
+      slot_values:
+        tongue_lip_swelling: "yes"
+    then:
+      risk_class: R3
+
+  - id: anaphylaxis_confirmed_breathing
+    if:
+      domain: anaphylaxis
+      slots_present:
+        - breathing_difficulty_acute
+      slot_values:
+        breathing_difficulty_acute: "yes"
+    then:
+      risk_class: R3
+
+  - id: anaphylaxis_screening_clear
+    if:
+      domain: anaphylaxis
+      slot_values:
+        rash_hives: "no"
+        tongue_lip_swelling: "no"
+        breathing_difficulty_acute: "no"
+    then:
+      risk_class: R0
+
+  # ── Overdose ────────────────────────────────────────────────
+  - id: overdose_confirmed_intentional
+    if:
+      domain: overdose
+      slots_present:
+        - intent
+      slot_values:
+        intent: "intentional"
+    then:
+      risk_class: R3
+
+  - id: overdose_confirmed_altered
+    if:
+      domain: overdose
+      slots_present:
+        - consciousness_level
+      slot_values:
+        consciousness_level: "altered"
+    then:
+      risk_class: R3
+
+  - id: overdose_screening_clear
+    if:
+      domain: overdose
+      slot_values:
+        intent: "accidental"
+        consciousness_level: "alert"
+    then:
+      risk_class: R2
+
+  # ── Stroke Symptoms (BE-FAST) ────────────────────────────────
+  - id: stroke_confirmed_balance
+    if:
+      domain: stroke_symptoms
+      slot_values:
+        balance_deficit: "yes"
+    then:
+      risk_class: R3
+
+  - id: stroke_confirmed_vision
+    if:
+      domain: stroke_symptoms
+      slot_values:
+        vision_change: "yes"
+    then:
+      risk_class: R3
+
+  - id: stroke_confirmed_facial_droop
+    if:
+      domain: stroke_symptoms
+      slots_present:
+        - facial_droop
+      slot_values:
+        facial_droop: "yes"
+    then:
+      risk_class: R3
+
+  - id: stroke_confirmed_arm_weakness
+    if:
+      domain: stroke_symptoms
+      slots_present:
+        - arm_weakness
+      slot_values:
+        arm_weakness: "yes"
+    then:
+      risk_class: R3
+
+  - id: stroke_confirmed_speech
+    if:
+      domain: stroke_symptoms
+      slots_present:
+        - speech_slurring
+      slot_values:
+        speech_slurring: "yes"
+    then:
+      risk_class: R3
+
+  - id: stroke_screening_clear
+    if:
+      domain: stroke_symptoms
+      slot_values:
+        balance_deficit: "no"
+        vision_change: "no"
+        facial_droop: "no"
+        arm_weakness: "no"
+        speech_slurring: "no"
+    then:
+      risk_class: R0
+
+  # ── Exertional Dyspnea ──────────────────────────────────────
+  - id: exertional_dyspnea_new_onset
+    if:
+      domain: exertional_dyspnea
+      slot_values:
+        dyspnea_onset: "new"
+    then:
+      risk_class: R3
+
+  - id: exertional_dyspnea_chronic
+    if:
+      domain: exertional_dyspnea
+      slot_values:
+        dyspnea_onset: "chronic"
+    then:
+      risk_class: R1
+
+  - id: exertional_dyspnea_screening_clear
+    if:
+      domain: exertional_dyspnea
+      slot_values:
+        dyspnea_onset: "chronic"
+    then:
+      risk_class: R0
+
+  # ── Abnormal BP ────────────────────────────────────────────
+  - id: abnormal_bp_critical_threshold
+    if:
+      domain: abnormal_bp
+      slots_present:
+        - bp_critical
+      slot_values:
+        bp_critical: "yes"
+    then:
+      risk_class: R3
+
+  - id: abnormal_bp_any_report
+    if:
+      domain: abnormal_bp
+      slots_present:
+        - bp_report_confirmed
+      slot_values:
+        bp_report_confirmed: "yes"
+    then:
+      risk_class: R2
+
+  # ── Anticoagulant Hold Failure ─────────────────────────────
+  - id: anticoag_still_taking
+    if:
+      domain: anticoagulant_hold_failure
+      slots_present:
+        - anticoag_still_taking
+      slot_values:
+        anticoag_still_taking: "yes"
+    then:
+      risk_class: R2
+
+  - id: anticoag_hold_compliant
+    if:
+      domain: anticoagulant_hold_failure
+      slot_values:
+        anticoag_still_taking: "no"
+    then:
+      risk_class: R0
+
+  # ── NPO Violation ─────────────────────────────────────────
+  - id: npo_recent_intake
+    if:
+      domain: npo_violation
+      slots_present:
+        - npo_last_intake_time
+      slot_values:
+        npo_intake_recent: "yes"
+    then:
+      risk_class: R2
+
+  - id: npo_compliant
+    if:
+      domain: npo_violation
+      slot_values:
+        npo_intake_recent: "no"
+    then:
+      risk_class: R0
+
+  # ── Acute Illness Pre-Op ──────────────────────────────────
+  - id: preop_illness_fever
+    if:
+      domain: acute_illness_preop
+      slots_present:
+        - illness_fever_present
+      slot_values:
+        illness_fever_present: "yes"
+    then:
+      risk_class: R2
+
+  - id: preop_illness_respiratory
+    if:
+      domain: acute_illness_preop
+      slots_present:
+        - illness_respiratory_symptoms
+      slot_values:
+        illness_respiratory_symptoms: "yes"
+    then:
+      risk_class: R2
+
+  - id: preop_illness_gi
+    if:
+      domain: acute_illness_preop
+      slots_present:
+        - illness_gi_symptoms
+      slot_values:
+        illness_gi_symptoms: "yes"
+    then:
+      risk_class: R2
+
+  - id: preop_illness_clear
+    if:
+      domain: acute_illness_preop
+      slot_values:
+        illness_fever_present: "no"
+        illness_respiratory_symptoms: "no"
+        illness_gi_symptoms: "no"
+    then:
+      risk_class: R0
+
+  # ── Domestic Safety Concern ──────────────────────────────────
+  - id: domestic_safety_immediate_danger
+    if:
+      domain: domestic_safety_concern
+      slots_present:
+        - immediate_danger
+      slot_values:
+        immediate_danger: "yes"
+    then:
+      risk_class: R2
+
+  - id: domestic_safety_not_safe_to_talk
+    if:
+      domain: domestic_safety_concern
+      slots_present:
+        - safe_to_talk
+      slot_values:
+        safe_to_talk: "no"
+    then:
+      risk_class: R2
+
+  - id: domestic_safety_screening_clear
+    if:
+      domain: domestic_safety_concern
+      slot_values:
+        safe_to_talk: "yes"
+        immediate_danger: "no"
+    then:
+      risk_class: R0
+
+  # ── Context-aware risk rules ─────────────────────────────────────────
+  # These rules require BOTH slot conditions AND patient context conditions
+  # to fire. When patient_context is None, context conditions are treated
+  # as non-matching (fail closed).
+
+  - id: sob_chf_decompensation
+    if:
+      domain: shortness_of_breath_rest
+      slots_present:
+        - sob_severity
+      slot_values:
+        sob_severity: "moderate"
+      context:
+        patient_has_condition: ["I50.*"]
+    then:
+      risk_class: R2
+
+  - id: sob_severe_chf_decompensation
+    if:
+      domain: shortness_of_breath_rest
+      slots_present:
+        - sob_severity
+      slot_values:
+        sob_severity: "severe"
+      context:
+        patient_has_condition: ["I50.*"]
+    then:
+      risk_class: R2
+
+  - id: confusion_polypharmacy
+    if:
+      domain: altered_mental_status
+      slots_present:
+        - confusion_reported
+      slot_values:
+        confusion_reported: "yes"
+      context:
+        medication_count_above: 10
+    then:
+      risk_class: R2
+
+  - id: weight_gain_chf_fluid_overload
+    if:
+      domain: weight_gain_sudden
+      slots_present:
+        - weight_change_lbs
+        - weight_gain_significant
+      slot_values:
+        weight_gain_significant: "yes"
+      context:
+        patient_has_condition: ["I50.*"]
+    then:
+      risk_class: R2
+
+hard_escalate_domains:
+  - suicidal_ideation
+  - homicidal_ideation
+
+turn_outcomes:
+  - proceed
+  - clarify
+  - escalate
+  - handoff
+  - end
+
+# ══════════════════════════════════════════════════════════════════════════════
+# Domain Suppression Rules
+# ══════════════════════════════════════════════════════════════════════════════
+# These rules allow an R1 domain firing at high confidence to suppress
+# an R2/R3 domain, reducing false escalations.
+# The flow engine must be updated separately to consume these rules.
+
+domain_suppression:
+  # ── Wound domains ─────────────────────────────────────────────────────
+  # When R1 wound_concern fires at medium/high confidence, suppress R2 wound_infection
+  # at low/medium confidence (not high - genuine infection signals should still escalate)
+  - suppressor: wound_concern
+    suppressed_domains:
+      - wound_infection
+    condition:
+      suppressor_min_confidence: medium  # medium or high
+      suppressed_max_confidence: medium  # low or medium (not high)
+    reason: "Routine wound concern (R1) contradicts infection (R2) at lower confidence"
+
+  # ── Chest pain domains ────────────────────────────────────────────────
+  # When R1 reproducible_chest_discomfort fires, suppress R3 chest_pain at low/medium
+  - suppressor: reproducible_chest_discomfort
+    suppressed_domains:
+      - chest_pain
+    condition:
+      suppressor_min_confidence: medium
+      suppressed_max_confidence: medium
+    reason: "Reproducible pattern suggests non-ACS chest pain"
+
+  # ── Glucose domains ───────────────────────────────────────────────────
+  # When R1 glucose_out_of_range fires, suppress R3 dka_hhs at low/medium
+  - suppressor: glucose_out_of_range
+    suppressed_domains:
+      - dka_hhs
+      - severe_hypoglycemia
+    condition:
+      suppressor_min_confidence: medium
+      suppressed_max_confidence: medium
+    reason: "Routine glucose management (R1) vs emergency (R3)"
+
+  # ── Medication domains ────────────────────────────────────────────────
+  # When R1 medication fires, suppress R3 overdose at low/medium
+  - suppressor: medication
+    suppressed_domains:
+      - overdose
+    condition:
+      suppressor_min_confidence: medium
+      suppressed_max_confidence: medium
+    reason: "Medication inquiry (R1) vs overdose (R3)"
+
+  # ── Oral intake domains ───────────────────────────────────────────────
+  # When R1 poor_oral_intake fires, suppress R2 persistent_vomiting at low/medium
+  - suppressor: poor_oral_intake
+    suppressed_domains:
+      - persistent_vomiting
+    condition:
+      suppressor_min_confidence: medium
+      suppressed_max_confidence: medium
+    reason: "Appetite concern (R1) vs persistent vomiting (R2)"
+
+  # ── Pain domains ──────────────────────────────────────────────────────
+  # When R1 worsening_chronic_pain fires, suppress R2 uncontrolled_pain at low/medium
+  - suppressor: worsening_chronic_pain
+    suppressed_domains:
+      - uncontrolled_pain
+    condition:
+      suppressor_min_confidence: medium
+      suppressed_max_confidence: medium
+    reason: "Chronic pain management (R1) vs acute uncontrolled pain (R2)"
diff --git a/decision/journeys/annual_wellness_visit.yaml b/decision/journeys/annual_wellness_visit.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..2071cc8e7985ee875966f44dbdc1c18f7b72bca9
--- /dev/null
+++ b/decision/journeys/annual_wellness_visit.yaml
@@ -0,0 +1,58 @@
+wedge_type: awv
+display_name: Annual Wellness Visit
+description: >-
+  30-day annual wellness visit preparation journey. Voice calls with SMS
+  reminders. Initial outreach uses the full 12-step agenda. Subsequent calls
+  use abbreviated agendas focused on screening reminders and visit preparation.
+default_duration_days: 30
+steps:
+  - step_id: initial_outreach
+    channel: voice
+    schedule:
+      offset_days: 30
+      window_hours: [9, 17]
+    agenda_sequence:
+      - awv_intro
+      - health_history_update
+      - medication_list_review
+      - family_history_update
+      - functional_status
+      - fall_risk_screening
+      - screening_reminders
+      - immunization_reminders
+      - advance_directives
+      - depression_screening
+      - social_determinants
+      - closing
+    teachback_steps: []
+    max_retries: 3
+    retry_delay_hours: 2
+
+  - step_id: reminder_call
+    channel: voice
+    schedule:
+      offset_days: 7
+      window_hours: [9, 17]
+    agenda_sequence:
+      - awv_intro
+      - screening_reminders
+      - immunization_reminders
+      - social_determinants
+      - closing
+    teachback_steps: []
+    max_retries: 2
+    retry_delay_hours: 4
+
+  - step_id: visit_prep_call
+    channel: voice
+    schedule:
+      offset_days: 2
+      window_hours: [9, 17]
+    agenda_sequence:
+      - awv_intro
+      - medication_list_review
+      - screening_reminders
+      - closing
+    teachback_steps: []
+    max_retries: 2
+    retry_delay_hours: 2
diff --git a/decision/journeys/gap_closure.yaml b/decision/journeys/gap_closure.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..eb3a4521212d6fde2c089680f3bc5f6fd0790637
--- /dev/null
+++ b/decision/journeys/gap_closure.yaml
@@ -0,0 +1,91 @@
+wedge_type: gap_closure
+display_name: Gap Closure
+description: >-
+  30-90 day care gap closure journey. SMS-first channel strategy with voice
+  call escalation for patients who do not respond to SMS reminders. SMS
+  messages are template-driven and do NOT pass through the DCE pipeline.
+  Only voice calls invoke the engine. Voice calls use a 7-step agenda
+  focused on gap identification, barrier assessment, and scheduling assistance.
+default_duration_days: 90
+steps:
+  # Step 1: SMS reminder (template-driven, does not invoke DCE)
+  - step_id: sms_reminder_1
+    channel: sms
+    schedule:
+      offset_days: 1
+      window_hours: [9, 20]
+    agenda_sequence: []
+    teachback_steps: []
+    max_retries: 0
+    retry_delay_hours: 0
+
+  # Step 2: SMS reminder (template-driven, does not invoke DCE)
+  - step_id: sms_reminder_2
+    channel: sms
+    schedule:
+      offset_days: 7
+      window_hours: [9, 20]
+    agenda_sequence: []
+    teachback_steps: []
+    max_retries: 0
+    retry_delay_hours: 0
+
+  # Step 3: SMS reminder (template-driven, does not invoke DCE)
+  - step_id: sms_reminder_3
+    channel: sms
+    schedule:
+      offset_days: 14
+      window_hours: [9, 20]
+    agenda_sequence: []
+    teachback_steps: []
+    max_retries: 0
+    retry_delay_hours: 0
+
+  # Step 4: First voice call — full 7-step gap closure agenda
+  - step_id: initial_outreach_call
+    channel: voice
+    schedule:
+      offset_days: 21
+      window_hours: [9, 17]
+    agenda_sequence:
+      - gap_intro
+      - gap_identification
+      - barrier_assessment
+      - motivational_support
+      - scheduling_assistance
+      - questions
+      - closing
+    teachback_steps: []
+    max_retries: 3
+    retry_delay_hours: 2
+
+  # Step 5: Follow-up voice call — abbreviated agenda
+  - step_id: follow_up_call
+    channel: voice
+    schedule:
+      offset_days: 45
+      window_hours: [9, 17]
+    agenda_sequence:
+      - gap_intro
+      - gap_identification
+      - scheduling_assistance
+      - closing
+    teachback_steps: []
+    max_retries: 2
+    retry_delay_hours: 4
+
+  # Step 6: Final voice call — last attempt
+  - step_id: final_outreach_call
+    channel: voice
+    schedule:
+      offset_days: 75
+      window_hours: [9, 17]
+    agenda_sequence:
+      - gap_intro
+      - gap_identification
+      - barrier_assessment
+      - scheduling_assistance
+      - closing
+    teachback_steps: []
+    max_retries: 2
+    retry_delay_hours: 4
diff --git a/decision/journeys/health_risk_assessment.yaml b/decision/journeys/health_risk_assessment.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..431c5f0f5741b4552897ec2fd291cb3fbd063942
--- /dev/null
+++ b/decision/journeys/health_risk_assessment.yaml
@@ -0,0 +1,45 @@
+wedge_type: hra
+display_name: Health Risk Assessment
+description: >-
+  14-day health risk assessment journey. Voice calls with SMS reminders.
+  Initial call uses the full 10-step agenda covering chronic conditions,
+  functional status, mental health screening, social determinants, and
+  preventive care review. Follow-up call uses abbreviated agenda for
+  incomplete sections.
+default_duration_days: 14
+steps:
+  - step_id: initial_hra_call
+    channel: voice
+    schedule:
+      offset_days: 1
+      window_hours: [9, 17]
+    agenda_sequence:
+      - hra_intro
+      - chronic_condition_inventory
+      - functional_status_assessment
+      - mental_health_screen
+      - social_determinants_screen
+      - medication_burden_review
+      - preventive_care_review
+      - care_plan_summary
+      - closing
+      - wrap_up
+    teachback_steps: []
+    max_retries: 3
+    retry_delay_hours: 2
+
+  - step_id: followup_hra_call
+    channel: voice
+    schedule:
+      offset_days: 7
+      window_hours: [9, 17]
+    agenda_sequence:
+      - hra_intro
+      - mental_health_screen
+      - social_determinants_screen
+      - preventive_care_review
+      - care_plan_summary
+      - closing
+    teachback_steps: []
+    max_retries: 2
+    retry_delay_hours: 4
diff --git a/decision/journeys/post_discharge_engagement.yaml b/decision/journeys/post_discharge_engagement.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0be50561587b0488ce1eb4981a0f308e7cf48dae
--- /dev/null
+++ b/decision/journeys/post_discharge_engagement.yaml
@@ -0,0 +1,120 @@
+wedge_type: pde
+display_name: Post-Discharge Engagement
+description: >-
+  3-30 day post-discharge follow-up journey. Voice calls with SMS reminders.
+  Day 1 uses the full 14-step agenda. Subsequent calls use abbreviated agendas
+  focused on evolving patient needs.
+default_duration_days: 30
+steps:
+  - step_id: day1_call
+    channel: voice
+    schedule:
+      offset_days: 1
+      window_hours: [9, 17]
+    agenda_sequence:
+      - intro_permission
+      - discharge_context
+      - teachback_diagnosis
+      - teachback_warning_signs
+      - general_status
+      - symptom_review
+      - meds_reconciliation
+      - appointments_check
+      - pending_tests
+      - home_services
+      - problem_solving
+      - emergency_plan
+      - closing
+      - wrap_up
+    teachback_steps:
+      - teachback_diagnosis
+      - teachback_warning_signs
+    max_retries: 3
+    retry_delay_hours: 2
+    conditional_probes:
+      - probe_id: chf_symptom_review
+        when:
+          patient_has_condition: ["I50.*"]
+        must_ask:
+          - "Have you been weighing yourself daily as instructed?"
+          - "Have you noticed any new or worsening swelling in your legs or ankles?"
+          - "Have you had any trouble breathing when lying flat?"
+        slots_to_extract: ["daily_weight_check", "edema_worsening", "orthopnea"]
+        reason: "CHF-specific symptom monitoring per AHA guidelines"
+      - probe_id: copd_symptom_review
+        when:
+          patient_has_condition: ["J44.*", "J43.*"]
+        must_ask:
+          - "Have you noticed any change in your sputum color or amount?"
+          - "Are you using your rescue inhaler more than usual?"
+        slots_to_extract: ["sputum_change", "rescue_inhaler_frequency"]
+        reason: "COPD exacerbation early detection"
+      - probe_id: diabetes_symptom_review
+        when:
+          patient_has_condition: ["E11.*", "E10.*"]
+        must_ask:
+          - "Have you been checking your blood sugar regularly?"
+          - "Have you had any episodes of very high or very low blood sugar?"
+        slots_to_extract: ["glucose_monitoring", "glucose_extremes"]
+        reason: "Post-discharge glucose management"
+    pre_populated_slots:
+      - slot: discharge_med_count
+        source_field: discharge_info.discharge_medications
+        reason: "Pre-populate from discharge medication list"
+
+  - step_id: day3_call
+    channel: voice
+    schedule:
+      offset_days: 3
+      window_hours: [9, 17]
+    agenda_sequence:
+      - intro_permission
+      - general_status
+      - symptom_review
+      - meds_reconciliation
+      - closing
+    teachback_steps: []
+    max_retries: 2
+    retry_delay_hours: 4
+
+  - step_id: day7_call
+    channel: voice
+    schedule:
+      offset_days: 7
+      window_hours: [9, 17]
+    agenda_sequence:
+      - intro_permission
+      - appointments_check
+      - problem_solving
+      - closing
+    teachback_steps: []
+    max_retries: 2
+    retry_delay_hours: 4
+
+  - step_id: day14_call
+    channel: voice
+    schedule:
+      offset_days: 14
+      window_hours: [9, 17]
+    agenda_sequence:
+      - intro_permission
+      - general_status
+      - symptom_review
+      - closing
+    teachback_steps: []
+    max_retries: 2
+    retry_delay_hours: 4
+
+  - step_id: day30_call
+    channel: voice
+    schedule:
+      offset_days: 30
+      window_hours: [9, 17]
+    agenda_sequence:
+      - intro_permission
+      - general_status
+      - emergency_plan
+      - closing
+    teachback_steps: []
+    max_retries: 2
+    retry_delay_hours: 4
diff --git a/decision/journeys/pre_op_optimization.yaml b/decision/journeys/pre_op_optimization.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4f9f051739e6ad021ee4c24af7ad0e5b7ffce76a
--- /dev/null
+++ b/decision/journeys/pre_op_optimization.yaml
@@ -0,0 +1,83 @@
+wedge_type: pre_op
+display_name: Pre-Op Optimization
+description: >-
+  7-90 day pre-surgery optimization journey. Voice calls with SMS reminders.
+  Initial call uses the full 10-step agenda. Subsequent calls use abbreviated
+  agendas focused on compliance verification and anxiety management.
+default_duration_days: 90
+steps:
+  - step_id: initial_assessment
+    channel: voice
+    schedule:
+      offset_days: 7
+      window_hours: [9, 17]
+    agenda_sequence:
+      - preop_intro
+      - health_history_update
+      - medication_review
+      - allergy_verification
+      - npo_status
+      - anxiety_screening
+      - procedure_prep
+      - logistics
+      - questions
+      - closing
+    teachback_steps:
+      - npo_status
+    max_retries: 3
+    retry_delay_hours: 2
+    conditional_probes:
+      - probe_id: anticoagulant_hold_check
+        when:
+          patient_on_medication_class: ["anticoagulant", "DOAC"]
+        must_ask:
+          - "Have you stopped taking your blood thinner as instructed?"
+          - "When did you take your last dose?"
+        slots_to_extract: ["anticoag_stopped", "last_anticoag_dose"]
+        reason: "Anticoagulant hold verification per ERAS guidelines"
+      - probe_id: glp1_hold_check
+        when:
+          patient_on_medication_class: ["GLP-1_agonist"]
+        must_ask:
+          - "Have you stopped taking your GLP-1 medication as instructed?"
+        slots_to_extract: ["glp1_stopped"]
+        reason: "GLP-1 agonist hold per updated ERAS guidelines"
+      - probe_id: insulin_management
+        when:
+          patient_on_medication_class: ["insulin"]
+        must_ask:
+          - "Have you adjusted your insulin dose as your surgeon instructed?"
+        slots_to_extract: ["insulin_adjusted"]
+        reason: "Perioperative insulin management"
+
+  - step_id: compliance_check
+    channel: voice
+    schedule:
+      offset_days: 3
+      window_hours: [9, 17]
+    agenda_sequence:
+      - preop_intro
+      - medication_review
+      - npo_status
+      - anxiety_screening
+      - closing
+    teachback_steps:
+      - npo_status
+    max_retries: 2
+    retry_delay_hours: 4
+
+  - step_id: day_before_call
+    channel: voice
+    schedule:
+      offset_days: 1
+      window_hours: [9, 17]
+    agenda_sequence:
+      - preop_intro
+      - npo_status
+      - logistics
+      - anxiety_screening
+      - closing
+    teachback_steps:
+      - npo_status
+    max_retries: 2
+    retry_delay_hours: 2
diff --git a/decision/orchestrator/conflict_resolution.yaml b/decision/orchestrator/conflict_resolution.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..158df221b12c785ddb0fdd1bc3a91e9aec75cc57
--- /dev/null
+++ b/decision/orchestrator/conflict_resolution.yaml
@@ -0,0 +1,79 @@
+# Cross-wedge conflict resolution rules.
+# When two wedges compete for the same contact slot, these rules decide
+# which one proceeds and what happens to the other.
+
+conflict_rules:
+  # PDE and Pre-Op on same day: PDE wins (higher priority_rank), Pre-Op defers
+  - rule_id: pde_preop_same_day
+    wedge_a: pde
+    wedge_b: pre_op
+    condition: same_day
+    winner: higher_priority
+    loser_action: defer_24h
+
+  # Tier 1 vs Tier 2 on same day: Tier 1 always wins
+  - rule_id: tier1_beats_tier2
+    wedge_a: pde
+    wedge_b: awv
+    condition: same_day
+    winner: higher_priority
+    loser_action: defer_24h
+
+  - rule_id: tier1_beats_gap
+    wedge_a: pde
+    wedge_b: gap_closure
+    condition: same_day
+    winner: higher_priority
+    loser_action: defer_24h
+
+  - rule_id: tier1_beats_hra
+    wedge_a: pde
+    wedge_b: hra
+    condition: same_day
+    winner: higher_priority
+    loser_action: defer_24h
+
+  - rule_id: preop_beats_awv
+    wedge_a: pre_op
+    wedge_b: awv
+    condition: same_day
+    winner: higher_priority
+    loser_action: defer_24h
+
+  - rule_id: preop_beats_gap
+    wedge_a: pre_op
+    wedge_b: gap_closure
+    condition: same_day
+    winner: higher_priority
+    loser_action: defer_24h
+
+  - rule_id: preop_beats_hra
+    wedge_a: pre_op
+    wedge_b: hra
+    condition: same_day
+    winner: higher_priority
+    loser_action: defer_24h
+
+  # Within Tier 2: AWV > Gap Closure > HRA (by priority_rank)
+  - rule_id: awv_beats_gap
+    wedge_a: awv
+    wedge_b: gap_closure
+    condition: same_day
+    winner: higher_priority
+    loser_action: defer_24h
+
+  - rule_id: awv_beats_hra
+    wedge_a: awv
+    wedge_b: hra
+    condition: same_day
+    winner: higher_priority
+    loser_action: defer_24h
+
+  - rule_id: gap_beats_hra
+    wedge_a: gap_closure
+    wedge_b: hra
+    condition: same_day
+    winner: higher_priority
+    loser_action: defer_24h
+
+default_loser_action: defer_24h
diff --git a/decision/orchestrator/contact_caps.yaml b/decision/orchestrator/contact_caps.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..301a065a9d2fa3d47214a98b0e5702529a1e6773
--- /dev/null
+++ b/decision/orchestrator/contact_caps.yaml
@@ -0,0 +1,16 @@
+global_max_per_day: 2
+global_max_per_week: 7
+channel_caps:
+  - channel: voice
+    max_per_day: 1
+    max_per_week: 5
+  - channel: sms
+    max_per_day: 2
+    max_per_week: 10
+  - channel: email
+    max_per_day: 1
+    max_per_week: 3
+quiet_hours:
+  start: "21:00"
+  end: "09:00"
+emergency_override: true
diff --git a/decision/orchestrator/enrollment_rules.yaml b/decision/orchestrator/enrollment_rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..272599c98f41c1cf6e521b3a567165468f7c6b01
--- /dev/null
+++ b/decision/orchestrator/enrollment_rules.yaml
@@ -0,0 +1,53 @@
+# Enrollment rules for journey lifecycle management.
+# Controls eligibility, deduplication, and cooldown periods.
+
+dedup_key_fields:
+  - patient_id
+  - wedge_type
+  - trigger_event_id
+
+enrollment_criteria:
+  - wedge_type: pde
+    required_events:
+      - adt_discharge
+    eligible_statuses:
+      - discharged
+    cooldown_days: 30
+    max_concurrent_journeys: 1
+
+  - wedge_type: pre_op
+    required_events:
+      - surgery_scheduled
+    eligible_statuses:
+      - scheduled
+    cooldown_days: 7
+    max_concurrent_journeys: 1
+
+  - wedge_type: awv
+    required_events:
+      - awv_eligible
+    eligible_statuses:
+      - eligible
+    cooldown_days: 365
+    max_concurrent_journeys: 1
+
+  - wedge_type: gap_closure
+    required_events:
+      - gap_identified
+    eligible_statuses:
+      - open
+    cooldown_days: 90
+    max_concurrent_journeys: 3
+
+  - wedge_type: hra
+    required_events:
+      - hra_eligible
+    eligible_statuses:
+      - eligible
+    cooldown_days: 365
+    max_concurrent_journeys: 1
+
+global_enrollment_settings:
+  max_active_journeys_per_patient: 3
+  require_consent: true
+  allow_re_enrollment: true
diff --git a/decision/orchestrator/wedge_priority.yaml b/decision/orchestrator/wedge_priority.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..97d047c81ac6000ff1ae1b592db6d02a6b5c4b26
--- /dev/null
+++ b/decision/orchestrator/wedge_priority.yaml
@@ -0,0 +1,16 @@
+priorities:
+  - wedge_type: pde
+    safety_tier: 1
+    priority_rank: 100
+  - wedge_type: pre_op
+    safety_tier: 1
+    priority_rank: 90
+  - wedge_type: awv
+    safety_tier: 2
+    priority_rank: 50
+  - wedge_type: gap_closure
+    safety_tier: 2
+    priority_rank: 40
+  - wedge_type: hra
+    safety_tier: 2
+    priority_rank: 30
diff --git a/decision/orchestrator/wedge_suppression.yaml b/decision/orchestrator/wedge_suppression.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5af11f58704fe23630ddf5dd6957015107dc6244
--- /dev/null
+++ b/decision/orchestrator/wedge_suppression.yaml
@@ -0,0 +1,78 @@
+# Temporal suppression rules for cross-wedge contact orchestration.
+# After certain events, suppress outbound contacts for specified wedges.
+# Escalation lock suppression blocks ALL wedges for ALL channels.
+
+suppression_rules:
+  # After any PDE voice call, suppress routine wedges for 24 hours
+  - rule_id: pde_call_suppresses_routine
+    trigger_wedge: pde
+    trigger_event: call_completed
+    suppress_wedges:
+      - awv
+      - gap_closure
+      - hra
+    suppress_channels:
+      - voice
+      - sms
+      - email
+    duration_hours: 24
+
+  # After any Pre-Op voice call, suppress routine wedges for 24 hours
+  - rule_id: preop_call_suppresses_routine
+    trigger_wedge: pre_op
+    trigger_event: call_completed
+    suppress_wedges:
+      - awv
+      - gap_closure
+      - hra
+    suppress_channels:
+      - voice
+      - sms
+      - email
+    duration_hours: 24
+
+  # After R3 escalation lock, suppress ALL wedges (all channels)
+  - rule_id: r3_lock_suppresses_all
+    trigger_wedge: any
+    trigger_event: escalation_lock_r3
+    suppress_wedges:
+      - pde
+      - pre_op
+      - awv
+      - gap_closure
+      - hra
+    suppress_channels:
+      - voice
+      - sms
+      - email
+    duration_hours: 24
+
+  # After R2 escalation lock, suppress ALL wedges (all channels)
+  - rule_id: r2_lock_suppresses_all
+    trigger_wedge: any
+    trigger_event: escalation_lock_r2
+    suppress_wedges:
+      - pde
+      - pre_op
+      - awv
+      - gap_closure
+      - hra
+    suppress_channels:
+      - voice
+      - sms
+      - email
+    duration_hours: 72
+
+  # After any voice call, suppress voice for same patient for 4 hours
+  - rule_id: voice_cooldown
+    trigger_wedge: any
+    trigger_event: call_completed
+    suppress_wedges:
+      - pde
+      - pre_op
+      - awv
+      - gap_closure
+      - hra
+    suppress_channels:
+      - voice
+    duration_hours: 4
diff --git a/decision/primitives/clarify.yaml b/decision/primitives/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e262cc20a807c6065b6df8411d10a2f2e0641074
--- /dev/null
+++ b/decision/primitives/clarify.yaml
@@ -0,0 +1,23 @@
+flow_id: clarify
+type: primitive
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: global_clarify
+      goal: "Ask the patient to repeat or clarify what they said"
+      tone: gentle_professional
+      must_include:
+        - "understand"
+      must_ask:
+        - "could you say that again"
+      must_not:
+        - "diagnos"
+      max_questions: 1
+    collects:
+      - clarification_text
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/primitives/consent.yaml b/decision/primitives/consent.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c2fb2e865a355db5628652f343d59270ca6a9ae5
--- /dev/null
+++ b/decision/primitives/consent.yaml
@@ -0,0 +1,29 @@
+flow_id: consent
+type: primitive
+
+required_slots:
+  - consent_given
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: consent_request
+      goal: "Obtain verbal consent to proceed with post-discharge check-in"
+      tone: warm_professional
+      must_include:
+        - "consent"
+        - "proceed"
+      must_ask:
+        - "okay to continue"
+      must_not:
+        - "required"
+        - "must"
+        - "have to"
+      max_questions: 1
+    collects:
+      - consent_given
+
+exit:
+  on_complete: recovery_checkin
+  on_refused: end_no_consent
diff --git a/decision/primitives/end_identity_failed.yaml b/decision/primitives/end_identity_failed.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1e10c65986d65c51293f6826a09aa2c772c3eb79
--- /dev/null
+++ b/decision/primitives/end_identity_failed.yaml
@@ -0,0 +1,27 @@
+flow_id: end_identity_failed
+type: primitive
+
+# Terminal state when identity verification fails after max attempts.
+# Per HIPAA telephone rules: do not disclose which identifier was wrong.
+# Apologize, cite privacy standards, and end the clinical portion.
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: end_identity_failed
+      goal: "End the call due to identity verification failure, citing privacy standards"
+      tone: warm_professional
+      must_include:
+        - "privacy"
+        - "verify"
+      must_ask: []
+      must_not:
+        - "wrong"
+        - "incorrect"
+        - "mismatch"
+        - "diagnos"
+        - "condition"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/primitives/end_no_consent.yaml b/decision/primitives/end_no_consent.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0f2fb6d3b8fe52cb58d7c7a92b6bfa9a2d141a64
--- /dev/null
+++ b/decision/primitives/end_no_consent.yaml
@@ -0,0 +1,22 @@
+flow_id: end_no_consent
+type: primitive
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: end_no_consent
+      goal: "Acknowledge the patient's decision to decline and end the call respectfully"
+      tone: warm_respectful
+      must_include:
+        - "understand"
+        - "respect"
+      must_ask: []
+      must_not:
+        - "must"
+        - "have to"
+        - "required"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/primitives/greeting.yaml b/decision/primitives/greeting.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..99d708ee7adf75d3984aaa5f3d6ddd82a9a4fd6b
--- /dev/null
+++ b/decision/primitives/greeting.yaml
@@ -0,0 +1,22 @@
+flow_id: greeting
+type: primitive
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: greeting_intro
+      goal: "Greet the patient warmly and introduce yourself as Avery, a post-discharge care assistant"
+      tone: warm_professional
+      must_include:
+        - "Avery"
+        - "checking in"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "doctor"
+        - "nurse"
+      max_questions: 0
+
+exit:
+  on_complete: identity_verify
diff --git a/decision/primitives/handoff.yaml b/decision/primitives/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f0dce7f032e509092f912663e1f4ad0f74cf3ea6
--- /dev/null
+++ b/decision/primitives/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: primitive
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: global_handoff_notice
+      goal: "Let the patient know they will be connected with a person who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "someone"
+      must_ask: []
+      must_not:
+        - "goodbye"
+        - "diagnos"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: global_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/primitives/identity_verify.yaml b/decision/primitives/identity_verify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ed104ce855ff8f14377fb0871af851f948777fec
--- /dev/null
+++ b/decision/primitives/identity_verify.yaml
@@ -0,0 +1,36 @@
+flow_id: identity_verify
+type: primitive
+
+# Joint Commission NPSG.01.01.01: Use at least two patient identifiers.
+# HIPAA telephone rules: full name + at least two identifying pieces of info.
+# For outbound calls, the system already knows the patient's identity from
+# the scheduling system.  We confirm name + DOB = two-factor verification.
+required_slots:
+  - patient_name_confirm
+  - patient_dob
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: identity_name_dob_request
+      goal: "Verify patient identity by asking for their full name and date of birth"
+      tone: warm_professional
+      must_include:
+        - "verify"
+        - "name"
+        - "date of birth"
+      must_ask:
+        - "full name"
+        - "date of birth"
+      must_not:
+        - "diagnos"
+        - "social security"
+        - "medical record"
+      max_questions: 2
+    collects:
+      - patient_name_confirm
+      - patient_dob
+
+exit:
+  on_complete: consent
diff --git a/decision/primitives/recovery_checkin.yaml b/decision/primitives/recovery_checkin.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8ecedf107f12dc9c8b8aeb1d2ba71c4a852fd377
--- /dev/null
+++ b/decision/primitives/recovery_checkin.yaml
@@ -0,0 +1,64 @@
+flow_id: recovery_checkin
+type: primitive
+
+required_slots:
+  - pain_level
+  - medication_adherence
+  - activity_level
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: recovery_pain_check
+      goal: "Ask about current pain level and general recovery"
+      tone: warm_empathetic
+      must_include:
+        - "recovery"
+        - "pain"
+      must_ask:
+        - "How are you feeling"
+        - "pain"
+      must_not:
+        - "diagnos"
+        - "should be"
+      max_questions: 2
+    collects:
+      - pain_level
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: recovery_medication_check
+      goal: "Check medication adherence and any issues"
+      tone: warm_professional
+      must_include:
+        - "medication"
+      must_ask:
+        - "taking your medications"
+      must_not:
+        - "must"
+        - "have to"
+      max_questions: 2
+    collects:
+      - medication_adherence
+
+  - step: 3
+    type: ask
+    response_spec:
+      id: recovery_activity_check
+      goal: "Check activity level and mobility"
+      tone: warm_encouraging
+      must_include:
+        - "activity"
+      must_ask:
+        - "getting around"
+      must_not:
+        - "should be doing more"
+      max_questions: 1
+    collects:
+      - activity_level
+
+exit:
+  on_complete: wrap_up
+  on_concern: evaluate_concern
diff --git a/decision/primitives/stt_repair.yaml b/decision/primitives/stt_repair.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..262f821558d47ddd2ace05368246fb1eea851e84
--- /dev/null
+++ b/decision/primitives/stt_repair.yaml
@@ -0,0 +1,22 @@
+flow_id: stt_repair
+type: primitive
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: stt_repair_request
+      goal: "Ask the patient to repeat what they said due to audio issues"
+      tone: gentle_professional
+      must_include:
+        - "hear"
+      must_ask:
+        - "say that again"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/primitives/wrap_up.yaml b/decision/primitives/wrap_up.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3093f72f257b7c607a86b34805ee2b8748cbe0b4
--- /dev/null
+++ b/decision/primitives/wrap_up.yaml
@@ -0,0 +1,21 @@
+flow_id: wrap_up
+type: primitive
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: wrap_up_closing
+      goal: "Thank the patient, summarize any follow-ups, and close the call"
+      tone: warm_professional
+      must_include:
+        - "thank you"
+        - "care team"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/abnormal_bp/flows/clarify.yaml b/decision/taxonomy/abnormal_bp/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..69106a878aafc344812cd4155e1d0bfc3c3f6b59
--- /dev/null
+++ b/decision/taxonomy/abnormal_bp/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: abnormal_bp
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: abnormal_bp_clarify
+      goal: "Ask patient to describe their abnormal bp symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - abnormal_bp_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/abnormal_bp/flows/escalate_r1.yaml b/decision/taxonomy/abnormal_bp/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e62de9f3d253a0d241dc4facd395aa51e002c55a
--- /dev/null
+++ b/decision/taxonomy/abnormal_bp/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: abnormal_bp
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/abnormal_bp/flows/escalate_r2.yaml b/decision/taxonomy/abnormal_bp/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e7997739c5b314e46198fcc8b91f88f97a8e447b
--- /dev/null
+++ b/decision/taxonomy/abnormal_bp/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: abnormal_bp
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will be connected to discuss their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "connect"
+        - "important"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: urgent
+    response_spec:
+      id: r2_handoff
+      goal: "Warm transfer to nurse with context summary"
+      tone: professional
+      must_include:
+        - "connecting"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/abnormal_bp/flows/escalate_r3.yaml b/decision/taxonomy/abnormal_bp/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ce19eace6089262e8092dd61b00de65bbb2fad2d
--- /dev/null
+++ b/decision/taxonomy/abnormal_bp/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: abnormal_bp
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Instruct patient to call 911 immediately and inform them of nurse transfer"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/abnormal_bp/flows/handoff.yaml b/decision/taxonomy/abnormal_bp/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4110f824f8d3dcc3f09cc3fe31948598e1b51a6b
--- /dev/null
+++ b/decision/taxonomy/abnormal_bp/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: abnormal_bp
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: abnormal_bp_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: abnormal_bp_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/abnormal_bp/flows/safety_screen.yaml b/decision/taxonomy/abnormal_bp/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..59234ca0ea43b07de797abf6d8cd3f0ff6122d3b
--- /dev/null
+++ b/decision/taxonomy/abnormal_bp/flows/safety_screen.yaml
@@ -0,0 +1,37 @@
+flow_id: safety_screen
+type: screening
+domain: abnormal_bp
+
+required_slots:
+  - bp_report_confirmed
+  - bp_associated_symptoms
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: abnormal_bp_screen_step1
+      goal: "Gather details about BP reading and associated symptoms"
+      tone: calm_urgent
+      must_include:
+        - "blood pressure"
+      must_ask:
+        - "What was your blood pressure reading?"
+        - "Are you having any headache, vision changes, or chest pain?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - bp_report_confirmed
+      - bp_associated_symptoms
+      - bp_systolic
+      - bp_diastolic
+      - bp_critical
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_r2: escalate_r2
+  on_low_risk: escalate_r1
+  on_unclear: escalate_r2
diff --git a/decision/taxonomy/abnormal_bp/rules.yaml b/decision/taxonomy/abnormal_bp/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..64343f6c47c21a77f096f7e1a2c014d2bdf900d2
--- /dev/null
+++ b/decision/taxonomy/abnormal_bp/rules.yaml
@@ -0,0 +1,33 @@
+domain: abnormal_bp
+target_risk_class: R2
+
+decision_rules:
+  - id: abnormal_bp_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: abnormal_bp_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: abnormal_bp_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: abnormal_bp_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: abnormal_bp_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/abnormal_bp/triggers.yaml b/decision/taxonomy/abnormal_bp/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9a6f7c076468d07978f3089f20e4193aa848b50e
--- /dev/null
+++ b/decision/taxonomy/abnormal_bp/triggers.yaml
@@ -0,0 +1,75 @@
+domain: abnormal_bp
+priority: 41
+
+lexical_signals:
+  high:
+    phrases:
+      - "blood pressure readings very high at home"
+      - "blood pressure consistently above 160"
+      - "hypertensive readings at home"
+      - "blood pressure dangerously high"
+      - "BP won't come down"
+      - "blood pressure consistently elevated"
+    regex:
+      - "blood\\s+pressure.*(high|elevated|above\\s+1[6-9]\\d)"
+      - "BP.*(high|won'?t\\s+come)"
+  medium:
+    phrases:
+      - "blood pressure elevated at home"
+      - "home BP readings are high"
+      - "blood pressure not controlled"
+      - "readings above normal consistently"
+      - "blood pressure higher than usual"
+      # --- MINIMIZER coverage ---
+      - "blood pressure was a little high"
+      - "my numbers have been kind of elevated"
+      - "BP might be a bit off"
+      - "readings were a little higher than usual"
+      - "blood pressure seems higher but it's probably just stress"
+      - "machine said it was high but those things aren't always right"
+      - "numbers are up a bit"
+      - "pressure behind my eyes"
+      - "head feels kind of heavy"
+      - "felt a bit dizzy and checked my blood pressure"
+      - "took my blood pressure and it was kind of high"
+      - "blood pressure is running higher than normal"
+      - "headache and my blood pressure was up"
+      - "blood pressure is creeping up"
+      - "numbers aren't great but probably nothing"
+      - "BP has been bouncing around"
+    regex:
+      - "(blood\\s+pressure|BP|numbers|readings).{0,20}(a\\s+)?(little|bit|kind of|sort of|somewhat|slightly).{0,10}(high|elevated|up|off)"
+      - "(blood\\s+pressure|BP|numbers|readings).{0,20}(higher|up|elevated).{0,10}(than usual|than normal|lately|recently|this week)"
+      - "(blood\\s+pressure|BP).{0,20}(probably|might be|could be).{0,15}(stress|nothing|fine|okay|normal)"
+      - "(head|pressure|headache).{0,15}(heavy|pound|throb|pressure|tight).{0,20}(blood pressure|BP)"
+      - "(dizzy|lightheaded|blurry|headache).{0,25}(blood pressure|BP|check|reading|numbers)"
+      - "(machine|monitor|reading|cuff).{0,20}(said|showed|read|was).{0,15}(high|elevated|up|above)"
+      - "(took|checked|tested).{0,10}(my\\s+)?(blood\\s+pressure|BP).{0,15}(high|elevated|up|above|not great)"
+      - "(blood\\s+pressure|BP).{0,15}(creep|bounc|run|fluctuat|trend|climb).{0,10}(up|around|higher|ing)"
+      # --- specific readings ---
+      - "(blood\\s+pressure|BP|reading).{0,15}(was|is|showed|read)\\s+\\d{3}\\s*(over|/)\\s*\\d{2,3}"
+      # --- symptomatic high BP ---
+      - "(headache|vision|nosebleed|nose\\s+bleed).{0,25}(blood\\s+pressure|BP).{0,15}(high|elevated|up)"
+      # --- Reading + minimization (R2 recall) ---
+      - "(BP|blood pressure).{0,15}(\\d{2,3}).{0,30}(nothing|stress|probably|fine|okay)"
+      - "(\\d{3}).{0,10}(over|/).{0,10}(\\d{2,3}).{0,25}(probably|nothing|just|stress)"
+      - "(reading|number|BP).{0,20}(said|was|showed).{0,15}(\\d{3}).{0,20}(but|though|stress|nothing)"
+      # --- Symptom combinations with elevated reading ---
+      - "(headache|pounding|throbbing).{0,25}(elevated|high).{0,15}(reading|BP|blood pressure)"
+      - "(palpitations|racing|pounding).{0,25}(high|elevated).{0,15}(BP|blood pressure|reading)"
+      - "(dizzy|lightheaded|blurry).{0,25}(blood pressure|BP).{0,15}(checked|was|showed).{0,15}(high|elevated|\\d{3})"
+      # --- Machine skepticism with documented reading (should still escalate) ---
+      - "(machine|monitor|cuff).{0,20}(aren't|not).{0,15}(right|accurate).{0,20}(but|though|still).{0,20}(\\d{3}|high|elevated)"
+      - "(don't trust|not accurate).{0,25}(machine|monitor).{0,20}(said|showed|read).{0,15}(\\d{3}|high)"
+  low:
+    partials:
+      - "blood pressure"
+      - "BP readings"
+      - "hypertension"
+
+negation_handling:
+  patterns:
+    - "blood pressure normal"
+    - "BP is fine"
+    - "readings are good"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/acute_confusion/flows/clarify.yaml b/decision/taxonomy/acute_confusion/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..aee5b62ad60d9d5ed71c9d3ccc8ac46f1c4ad0ea
--- /dev/null
+++ b/decision/taxonomy/acute_confusion/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: acute_confusion
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: acute_confusion_clarify
+      goal: "Ask patient to describe their acute confusion symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - acute_confusion_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/acute_confusion/flows/escalate_r2.yaml b/decision/taxonomy/acute_confusion/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..56453291c86b1038d498ad70ebc7e86a59e02826
--- /dev/null
+++ b/decision/taxonomy/acute_confusion/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: acute_confusion
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/acute_confusion/flows/handoff.yaml b/decision/taxonomy/acute_confusion/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9479c0d6b7d31d289788d2b136addf9618797f60
--- /dev/null
+++ b/decision/taxonomy/acute_confusion/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: acute_confusion
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: acute_confusion_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: acute_confusion_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/acute_confusion/flows/safety_screen.yaml b/decision/taxonomy/acute_confusion/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..bec88a4d2984a457c3073b7f18055e879da142d8
--- /dev/null
+++ b/decision/taxonomy/acute_confusion/flows/safety_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: safety_screen
+type: screening
+domain: acute_confusion
+
+required_slots:
+  - confusion_onset
+  - orientation_status
+  - medication_changes
+  - recent_illness
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "confusion onset"
+        - "orientation status"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - confusion_onset
+      - orientation_status
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "medication changes"
+        - "recent illness"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - medication_changes
+      - recent_illness
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/decision/taxonomy/acute_confusion/rules.yaml b/decision/taxonomy/acute_confusion/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5e6dd70e1cf4493b0c7ecefb16eedc3aaa6f8953
--- /dev/null
+++ b/decision/taxonomy/acute_confusion/rules.yaml
@@ -0,0 +1,27 @@
+domain: acute_confusion
+target_risk_class: R2
+
+decision_rules:
+  - id: acute_confusion_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: acute_confusion_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: acute_confusion_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: acute_confusion_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/acute_confusion/triggers.yaml b/decision/taxonomy/acute_confusion/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..38c787698be6e30687c54b28723d673254585efc
--- /dev/null
+++ b/decision/taxonomy/acute_confusion/triggers.yaml
@@ -0,0 +1,296 @@
+domain: acute_confusion
+priority: 79
+
+lexical_signals:
+  high:
+    phrases:
+      - "suddenly confused"
+      - "new confusion"
+      - "acute delirium"
+      - "suddenly not making sense"
+      - "head feels scrambled"
+      - "doesn't know where he is"
+      - "doesn't know where she is"
+      - "doesn't recognize me"
+      - "talking gibberish"
+      - "talking nonsense"
+      - "saying things that make no sense"
+      - "completely disoriented"
+      - "woke up and didn't know who I was"
+      - "can't tell me what year it is"
+      - "thinks he is somewhere else"
+      - "thinks she is somewhere else"
+      - "not making any sense at all"
+      - "hallucinating and confused"
+      - "seeing things that are not there and confused"
+      - "confused and aggressive"
+    regex:
+      - "(sudden|new|acute)\\s+(confusion|delirium)"
+      - "doesn[']?t\\s+know\\s+where\\s+(they|he|she)"
+      - "disoriented\\s+and\\s+wasn[']?t\\s+before"
+      - "don[']?t\\s+know\\s+what\\s+day"
+      - "keep\\s+forgetting\\s+what\\s+I\\s+was\\s+doing"
+      - "doesn[']?t\\s+(recognize|know)\\s+(me|us|his|her|the|where)"
+      - "talking\\s+(gibberish|nonsense|crazy|rubbish|garbage|jibberish)"
+      - "(say|said|saying)\\s+(things|stuff|words).{0,10}(that\\s+)?(make|do)n?[']?t?\\s+(no\\s+)?sense"
+      - "(complete|total)ly\\s+(disoriented|confused|out\\s+of\\s+it|lost)"
+      - "(woke|wake).{0,10}up.{0,15}(didn[']?t|doesn[']?t|not)\\s+(know|recognize)"
+      - "can[']?t\\s+tell\\s+(me|us|you).{0,10}(what|where|who|the)"
+      - "thinks?\\s+(he|she|they|I).{0,5}(is|am|are)\\s+(somewhere|in\\s+a|at\\s+the|back\\s+in)"
+      - "(hallucinat|seeing\\s+things|hearing\\s+things).{0,15}(and\\s+)?(confused|disoriented)"
+      - "(confused|disoriented).{0,15}(and\\s+)?(aggressive|agitated|combative|violent|yelling)"
+  medium:
+    phrases:
+      - "acting confused"
+      - "not themselves today"
+      - "seems disoriented"
+      - "confused since this morning"
+      - "altered mental status"
+      - "not feeling right"
+      - "walking around in a fog"
+      - "acting off"
+      - "not as sharp today"
+      - "misplacing stuff"
+      - "keeps asking the same thing"
+      - "not acting like himself"
+      - "not acting like herself"
+      - "not acting like myself"
+      - "acting really weird"
+      - "got lost in his own house"
+      - "got lost in her own house"
+      - "couldn't figure out how to use the remote"
+      - "put the milk in the cupboard"
+      - "called me by the wrong name"
+      - "forgot where the bathroom is"
+      - "staring off into space"
+      - "eyes look glazed over"
+      - "just mumbling and not making sense"
+      - "couldn't finish a sentence"
+      - "words are all jumbled up"
+      - "tried to leave the house in pajamas at 3am"
+      - "thought it was morning when it was night"
+      - "keeps getting up and wandering around"
+      - "having trouble following the conversation"
+      # --- MINIMIZER coverage ---
+      - "just a little mixed up sometimes"
+      - "a bit forgetful lately"
+      - "thoughts are kind of jumbled"
+      - "brain won't cooperate"
+      - "probably just tired"
+      - "I'm fine, just a bit foggy"
+      - "just got confused for a minute"
+      - "a little bit spacey I guess"
+      - "he's always been a little forgetful"
+      - "she's just having an off day"
+      - "my mind keeps wandering"
+      - "having a hard time concentrating"
+      - "losing my train of thought"
+      - "thoughts keep sliding around"
+      - "brain keeps skipping"
+      # --- additional patterns ---
+      - "doesn't know what year it is"
+      - "thinks the kids are still little"
+      - "talking to people who aren't here"
+      - "tried to go to a job he retired from"
+    regex:
+      - "(can[']?t|keep)\\s+(remember|recall)"
+      - "(head|brain).*(scrambled|buffering|foggy|not working)"
+      - "keep\\s+(forgetting|losing)\\s+(my\\s+)?(train\\s+of\\s+thought|what)"
+      - "can[']?t\\s+remember\\s+things\\s+today"
+      - "brain[']?s\\s+buffering"
+      - "head[']?s\\s+not\\s+working"
+      - "sounded\\s+weird\\s+on\\s+the\\s+phone"
+      - "can[']?t\\s+think\\s+straight"
+      - "doesn[']?t\\s+track"
+      - "(acting|seems?|been)\\s+(really\\s+)?(off|weird|strange)"
+      - "(my|his|her)\\s+(head|brain|mind).*(off|foggy|cloudy|fuzzy|not right|skipping)"
+      - "misplac(e|ed|ing)\\s+(my|his|her|the)"
+      - "forgot\\s+(the\\s+)?(neighbor|day|where|what|why)"
+      - "(daughter|son|wife|husband|partner|sister|spouse)\\s+(says?|keeps?\\s+saying)\\s+(I[']?m|he[']?s|she[']?s)\\s+.?off"
+      - "not\\s+acting\\s+like\\s+(my|him|her|them)sel"
+      - "mentally\\s+.?off"
+      - "couldn[']?t\\s+orient"
+      - "(asked|saying)\\s+the\\s+same\\s+(question|thing)"
+      - "rereading.*(same|email|sentence)"
+      - "brain\\s+is\\s+skipping"
+      - "speech\\s+(is\\s+)?(sort\\s+of\\s+)?jumbled"
+      - "words\\s+(are\\s+)?coming\\s+out\\s+wrong"
+      - "called\\s+the\\s+\\w+\\s+the\\s+.?(fridge|microwave|oven)"
+      - "mixed\\s+up\\s+(sometimes|on)"
+      - "she[']?s\\s+acting\\s+really\\s+weird"
+      - "he[']?s\\s+acting\\s+really\\s+weird"
+      - "(been|was)\\s+acting.*off"
+      - "acting.{0,15}off"
+      - "(spouse|partner|wife|husband)\\s+said\\s+(I|he|she)\\s+was\\s+.?weird"
+      - "kept\\s+saying\\s+(she|he)\\s+needed\\s+to"
+      - "little\\s+weird\\s+mistakes"
+      - "been\\s+retired.*go\\s+to\\s+work"
+      - "(got|get|getting)\\s+lost\\s+(in\\s+)?(his|her|the|own)\\s+(own\\s+)?(house|home|room|yard)"
+      - "(put|left|placed).{0,10}(milk|keys|phone|remote|wallet).{0,10}(in\\s+the\\s+)?(cupboard|oven|fridge|freezer|wrong|weird)"
+      - "called\\s+(me|him|her|us).{0,10}(by\\s+)?(the\\s+)?wrong\\s+name"
+      - "forgot\\s+where\\s+(the\\s+)?(bathroom|kitchen|bedroom|door)"
+      - "(star|gaz).{0,5}(ing|ed)\\s+(off|into\\s+space|at\\s+nothing|blankly)"
+      - "eyes?.{0,10}(glaz|glass|blank|vacant|empty)"
+      - "(mumbl|mutter|rambl).{0,5}(ing|ed).{0,10}(not\\s+)?(mak|no\\s+sense)"
+      - "(can[']?t|couldn[']?t|unable)\\s+(finish|complete).{0,10}(a\\s+)?(sentence|thought|word)"
+      - "words?.{0,10}(jumbl|garbl|scrambl|mix)"
+      - "(tried|try|trying)\\s+to\\s+(leave|go\\s+out|walk\\s+out).{0,15}(pajama|nightgown|underwear|naked|middle\\s+of\\s+the\\s+night|3\\s*am|2\\s*am)"
+      - "thought\\s+it\\s+was\\s+(morning|night|day|tuesday|monday|\\d{4})"
+      - "(wander|roam|pace).{0,5}(ing|ed).{0,10}(around|aimless|the\\s+house|the\\s+hall)"
+      - "(trouble|difficulty|hard\\s+time).{0,10}(follow|track|understand).{0,10}(the\\s+)?(conversation|what)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(just|only).{0,10}(a\\s+)?(little|bit|slight).{0,15}(confused|mixed up|foggy|forgetful|spacey|scattered)"
+      - "(probably|might be).{0,15}(just|nothing|tired|medication|stress|age|old|getting older)"
+      - "(confused|foggy|forgetful|mixed up).{0,15}(but|though).{0,15}(fine|okay|managing|not that bad)"
+      - "(thoughts?|brain|head|mind).{0,15}(won'?t|not|isn'?t|doesn'?t).{0,10}(cooperat|work|focus|click|connect)"
+      - "(mind|thoughts?).{0,15}(wander|drift|slide|slip|scatter|jumble|scramble|all over)"
+      - "(hard|harder|having trouble|difficulty).{0,10}(concentrat|focus|think|follow|track|keep up)"
+  low:
+    partials:
+      - "confused"
+      - "disoriented"
+      - "delirium"
+      - "altered"
+      - "not making sense"
+      - "foggy"
+      - "scrambled"
+      - "mixed up"
+      - "spacey"
+      - "out of it"
+      - "acting off"
+      - "feel off"
+      - "feels off"
+      - "glazed"
+      - "incoherent"
+      - "wandering"
+      - "mumbling"
+      - "sundowning"
+      - "not oriented"
+
+negation_handling:
+  patterns:
+    - "not confused"
+    - "thinking clearly"
+    - "mental status is fine"
+    - "I can think clearly"
+    - "head is fine"
+    - "oriented and alert"
+    - "alert and oriented"
+    - "no confusion"
+    - "confusion resolved"
+    - "back to normal mentally"
+    - "sharp as usual"
+    - "no delirium"
+    - "mind is clear"
+    - "thinking clearly now"
+    - "not confused anymore"
+    - "confusion cleared up"
+    - "brain fog lifted"
+    - "acting like themselves again"
+    - "making sense now"
+    - "remembering things fine"
+    - "knows where he is"
+    - "knows where she is"
+    - "oriented to person place and time"
+    - "mental status is back to baseline"
+    # --- non-clinical confusion context (R1 scenarios) ---
+    - "confused about the instructions"
+    - "confused about my medications"
+    - "confused about the schedule"
+    - "confused about the timing"
+    - "confused about the paperwork"
+    - "confused about which pill"
+    - "confused by all the"
+    - "confused with the"
+    - "confused about what to do"
+    - "confused about when to"
+    - "got confused about"
+    - "a little confused about"
+    - "confused about my appointment"
+    - "confused about my discharge"
+    - "I get confused with all the medical"
+    - "confusing to keep track"
+    - "it's all a bit confusing"
+    - "the instructions were confusing"
+    - "no, I'm thinking clearly"
+    - "no confusion"
+    - "not confused"
+    - "I'm clear headed"
+    - "mind is fine"
+    - "no I haven't been confused"
+    # --- medication/instruction memory context ---
+    - "remember the dosage"
+    - "remember what the doctor"
+    - "remember what to take"
+    - "remember the instructions"
+    - "remember the schedule"
+    - "remember which pill"
+    - "remember how many"
+    - "remember what I was told"
+    - "remember if I"
+    - "remember what I"
+    - "remember which"
+    - "remember what my"
+    # --- wound care / administrative confusion context ---
+    - "confused about the whole process"
+    - "confused about the process"
+    - "confused about how this works"
+    - "confused about whether"
+    - "confused about how to"
+    - "confused with forms"
+    - "confused about forms"
+    - "confused about calling"
+    - "i get confused with"
+    - "mixed up with all these appointments"
+    - "mixed up with appointments"
+    - "mixed up on how this works"
+    - "can't remember the name"
+    - "can't remember which one"
+    - "can't remember which doctor"
+    - "can't remember the doctor"
+    - "can't remember who I saw"
+    - "can't remember her name"
+    - "can't remember his name"
+    - "probably nothing"
+    - "probably just need"
+    - "probably just a general"
+    - "probably just a check"
+    - "probably just age"
+    - "wound care"
+    - "dressing change"
+    - "bandage change"
+    - "changing the bandage"
+    - "sterile gauze"
+    - "buy gauze"
+    - "healing okay"
+    - "healing fine"
+    - "healing well"
+    - "healing right"
+    - "forgetting which pill"
+    - "forgetting the schedule"
+    - "forgetting what to take"
+    - "recall the dosage"
+    - "recall what the doctor"
+    - "mixed up about my medications"
+    - "mixed up about the schedule"
+    - "mixed up about what to take"
+    - "mixed up the pills"
+    - "mixed up my medications"
+    - "pharmacy label"
+    - "label says something different"
+    - "label says"
+    - "prescription says"
+    - "the bottle says"
+    - "medication question"
+    - "medication schedule"
+    - "dosing schedule"
+    - "asking about my"
+    - "question about my"
+    - "refill"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/acute_illness_preop/flows/clarify.yaml b/decision/taxonomy/acute_illness_preop/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9a19e9ae6cf221b0541b69d4cf5aeda0a6a3aeda
--- /dev/null
+++ b/decision/taxonomy/acute_illness_preop/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: acute_illness_preop
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: acute_illness_preop_clarify
+      goal: "Ask patient to describe how they are feeling before their surgery"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - acute_illness_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/acute_illness_preop/flows/escalate_r2.yaml b/decision/taxonomy/acute_illness_preop/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1c598ce629f1252f1a358283d4b6e31a8da709d1
--- /dev/null
+++ b/decision/taxonomy/acute_illness_preop/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: acute_illness_preop
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: acute_illness_preop_r2_escalation_notice
+      goal: "Inform patient that the surgical team will follow up same day about their illness before the procedure"
+      tone: calm_reassuring
+      must_include:
+        - "surgical team"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: surgical_nurse
+    urgency: same_day
+    response_spec:
+      id: acute_illness_preop_r2_handoff
+      goal: "Schedule same-day surgical team callback with illness context"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/acute_illness_preop/flows/escalate_r3.yaml b/decision/taxonomy/acute_illness_preop/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6be71bb0e0128b573b352e2b0465111d0d1551f8
--- /dev/null
+++ b/decision/taxonomy/acute_illness_preop/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: acute_illness_preop
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Instruct patient to call 911 immediately and inform them of nurse transfer"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/acute_illness_preop/flows/reassure_low_risk.yaml b/decision/taxonomy/acute_illness_preop/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a34b1e11c70d3c0fa4f89b3cf1ffa0247a40f884
--- /dev/null
+++ b/decision/taxonomy/acute_illness_preop/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: acute_illness_preop
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: acute_illness_preop_reassure
+      goal: "Acknowledge the patient's concern and note that their care team will be informed for routine follow-up before surgery"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/acute_illness_preop/flows/safety_screen.yaml b/decision/taxonomy/acute_illness_preop/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f2e9eaf865c3ba7009ba4842fbbd7f2c6d739e89
--- /dev/null
+++ b/decision/taxonomy/acute_illness_preop/flows/safety_screen.yaml
@@ -0,0 +1,55 @@
+flow_id: safety_screen
+type: screening
+domain: acute_illness_preop
+
+required_slots:
+  - illness_fever_present
+  - illness_respiratory_symptoms
+  - illness_gi_symptoms
+  - illness_onset_timing
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: acute_illness_preop_screen_step1
+      goal: "Assess whether the patient has a fever and respiratory symptoms"
+      tone: calm_urgent
+      must_include:
+        - "symptoms"
+      must_ask:
+        - "Do you have a fever or feel feverish?"
+        - "Are you experiencing any cough, sore throat, or trouble breathing?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - illness_fever_present
+      - illness_respiratory_symptoms
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: acute_illness_preop_screen_step2
+      goal: "Assess GI symptoms and when symptoms started"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "Have you had any nausea, vomiting, or diarrhea?"
+        - "When did you first start feeling sick?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - illness_gi_symptoms
+      - illness_onset_timing
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_r3: escalate_r3
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_r2
diff --git a/decision/taxonomy/acute_illness_preop/rules.yaml b/decision/taxonomy/acute_illness_preop/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e644965b64d49f097161e288634b58bec98b7441
--- /dev/null
+++ b/decision/taxonomy/acute_illness_preop/rules.yaml
@@ -0,0 +1,33 @@
+domain: acute_illness_preop
+target_risk_class: R2
+
+decision_rules:
+  - id: acute_illness_preop_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: acute_illness_preop_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: acute_illness_preop_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: acute_illness_preop_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: acute_illness_preop_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/acute_illness_preop/triggers.yaml b/decision/taxonomy/acute_illness_preop/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..420e3b91fe3ccf4e1ac46d52ee3b93e1e447a430
--- /dev/null
+++ b/decision/taxonomy/acute_illness_preop/triggers.yaml
@@ -0,0 +1,83 @@
+domain: acute_illness_preop
+priority: 69
+
+lexical_signals:
+  high:
+    phrases:
+      - "came down with a cold before surgery"
+      - "running a fever"
+      - "started coughing"
+      - "have the flu"
+      - "stomach bug before my procedure"
+      - "feel sick before surgery"
+      - "vomiting before my surgery"
+      - "diarrhea before my procedure"
+      - "woke up with a fever this morning"
+      - "sore throat and fever before my operation"
+      - "throwing up since last night"
+      - "coughing up phlegm before surgery"
+      - "came down with something before my procedure"
+      - "been sick the last few days and surgery is soon"
+      - "got sick right before surgery"
+      - "fever of 101 and surgery is tomorrow"
+      - "been vomiting and have surgery coming up"
+      - "chills and body aches before my procedure"
+    regex:
+      - "(fever|cold|flu|cough|vomit|diarrhea|throwing\\s+up|sick|ill).{0,25}(before|prior).{0,10}(surgery|procedure|operation)"
+      - "(surgery|procedure|operation).{0,25}(fever|cold|flu|cough|vomit|diarrhea|throwing\\s+up|sick|ill)"
+      - "(came\\s+down|come\\s+down|got|gotten).{0,15}(sick|cold|flu|bug|fever|ill).{0,20}(surgery|procedure|operation)"
+      - "(running|have|got|gotten|developed).{0,10}(a\\s+)?(fever|temperature).{0,20}(surgery|procedure|operation)"
+      - "(vomit|throw|threw).{0,10}(up|ing).{0,20}(surgery|procedure|operation|before|prior)"
+      - "(diarrhea|stomach\\s+bug|stomach\\s+flu|gi\\s+bug).{0,20}(surgery|procedure|operation|before|prior)"
+      - "(?<!no )(?<!not )(fever|cough|cold|flu).{0,15}(and|with).{0,15}(surgery|procedure|operation).{0,10}(tomorrow|soon|this\\s+week|coming\\s+up)"
+  medium:
+    phrases:
+      - "not feeling well before surgery"
+      - "feeling under the weather"
+      - "sore throat before procedure"
+      - "runny nose"
+      - "congested"
+      - "body aches before surgery"
+      - "feel a little off before my procedure"
+      - "might be coming down with something"
+      - "my kid has the flu and now I feel sick"
+      - "scratchy throat before surgery"
+      - "started sneezing a lot"
+      - "headache and chills before my operation"
+      - "not sure if I should still have surgery"
+      - "feeling achy and tired before my procedure"
+    regex:
+      - "(not\\s+feeling|don't\\s+feel).{0,10}(well|good|great|right).{0,20}(surgery|procedure|operation|before)"
+      - "(under\\s+the\\s+weather|coming\\s+down\\s+with).{0,20}(surgery|procedure|operation)"
+      - "(sore\\s+throat|runny\\s+nose|congested|stuffy|sneezing|body\\s+aches).{0,20}(surgery|procedure|operation|before)"
+  low:
+    partials:
+      - "sniffles"
+      - "stuffy nose"
+      - "feeling unwell"
+      - "not well"
+      - "caught a bug"
+
+negation_handling:
+  patterns:
+    - "feeling fine"
+    - "no fever"
+    - "not sick"
+    - "healthy for surgery"
+    - "feeling great"
+    - "no cold symptoms"
+    - "no cough"
+    - "no sore throat"
+    - "not vomiting"
+    - "no diarrhea"
+    - "feeling well"
+    - "in good health"
+    - "no illness"
+    - "feel fine before surgery"
+    - "no symptoms"
+    - "cleared for surgery"
+    - "healthy and ready"
+    - "no nausea"
+    - "haven't been sick"
+    - "no body aches"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/acute_limb_deficit/flows/clarify.yaml b/decision/taxonomy/acute_limb_deficit/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..654ac44e0c430f27b9dd0074d612ca80599bcd35
--- /dev/null
+++ b/decision/taxonomy/acute_limb_deficit/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: acute_limb_deficit
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: acute_limb_deficit_clarify
+      goal: "Ask patient to describe their acute limb deficit symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - acute_limb_deficit_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/acute_limb_deficit/flows/escalate_r2.yaml b/decision/taxonomy/acute_limb_deficit/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8c258c3c460ee4a5f5d1b64f7263271261dbe1a4
--- /dev/null
+++ b/decision/taxonomy/acute_limb_deficit/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: acute_limb_deficit
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/acute_limb_deficit/flows/escalate_r3.yaml b/decision/taxonomy/acute_limb_deficit/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..42562e0cc7d01ebc2bbc59a8526a2f036868cb74
--- /dev/null
+++ b/decision/taxonomy/acute_limb_deficit/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: acute_limb_deficit
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Instruct patient to call 911 immediately and inform them of nurse transfer"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/acute_limb_deficit/flows/handoff.yaml b/decision/taxonomy/acute_limb_deficit/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b8246e514656b21c6294a7f04c88e9551a38de4f
--- /dev/null
+++ b/decision/taxonomy/acute_limb_deficit/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: acute_limb_deficit
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: acute_limb_deficit_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: acute_limb_deficit_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/acute_limb_deficit/flows/safety_screen.yaml b/decision/taxonomy/acute_limb_deficit/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..bef67b9cf803030295d8084e891365874440dd67
--- /dev/null
+++ b/decision/taxonomy/acute_limb_deficit/flows/safety_screen.yaml
@@ -0,0 +1,54 @@
+flow_id: safety_screen
+type: screening
+domain: acute_limb_deficit
+
+required_slots:
+  - limb_affected
+  - onset_timing
+  - sensation_status
+  - movement_ability
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "limb affected"
+        - "onset timing"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - limb_affected
+      - onset_timing
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "sensation status"
+        - "movement ability"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - sensation_status
+      - movement_ability
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/decision/taxonomy/acute_limb_deficit/rules.yaml b/decision/taxonomy/acute_limb_deficit/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b3b12689cd01799ffb2eb6d8b08fb0234e3d6323
--- /dev/null
+++ b/decision/taxonomy/acute_limb_deficit/rules.yaml
@@ -0,0 +1,33 @@
+domain: acute_limb_deficit
+target_risk_class: R3
+
+decision_rules:
+  - id: acute_limb_deficit_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: acute_limb_deficit_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: acute_limb_deficit_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: acute_limb_deficit_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: acute_limb_deficit_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/acute_limb_deficit/triggers.yaml b/decision/taxonomy/acute_limb_deficit/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..186d51aa81dc3ffcce7c30d9f95de54756d78d57
--- /dev/null
+++ b/decision/taxonomy/acute_limb_deficit/triggers.yaml
@@ -0,0 +1,251 @@
+domain: acute_limb_deficit
+priority: 64
+
+lexical_signals:
+  high:
+    phrases:
+      # --- original ---
+      - "can't move my leg suddenly"
+      - "arm went numb and can't use it"
+      - "sudden loss of function in my hand"
+      - "limb is cold and pale"
+      - "sudden paralysis in my arm"
+      - "can't feel my leg anymore"
+      # --- expanded naturalistic ---
+      - "my arm suddenly went dead"
+      - "my leg just gave out and I can't move it"
+      - "woke up and can't move my arm"
+      - "one side of my body stopped working"
+      - "sudden weakness on one side"
+      - "face is drooping"
+      - "half my face went numb"
+      - "can't lift my arm at all"
+      - "my leg is completely numb and won't move"
+      - "arm just went limp out of nowhere"
+      - "sudden complete weakness in my leg"
+      - "can't feel or move my hand suddenly"
+      - "I think I might be having a stroke"
+      - "one arm is totally useless now"
+      - "sudden loss of feeling and movement in leg"
+      - "my leg went cold and turned white"
+      - "arm is pale and cold and I can't move it"
+      - "face drooping and arm won't work"
+      - "speech is slurred and arm is weak"
+    regex:
+      # --- original ---
+      - "sudden(ly)?\\s+(can'?t\\s+move|loss\\s+of|paralys|numb)"
+      - "limb.*(cold|pale|paralyz)"
+      # --- expanded ---
+      - "(arm|leg|hand|foot|limb)\\s+(just\\s+)?(went|gone|is)\\s+(dead|limp|numb|useless)"
+      - "can'?t\\s+(move|lift|feel|use)\\s+(my\\s+)?(arm|leg|hand|foot|left|right)"
+      - "(sudden|suddenly)\\s+(weakness|paralysis|numbness|loss)\\s+(in|of|on)"
+      - "one\\s+side\\s+(of\\s+)?(my\\s+)?(body|face)\\s+(stopped|went|is|not)\\s+(working|numb|weak|dead)"
+      - "face\\s+(is\\s+)?(drooping|droopy|sagging|numb|fallen)"
+      - "(having|think).*(stroke|CVA|\\bTIA\\b)"
+      - "(arm|leg|hand|foot)\\s+(is\\s+)?(completely|totally|entirely)\\s+(numb|weak|useless|dead|paralyz)"
+      - "(woke|wake)\\s+up.*(can'?t\\s+move|numb|paralyz|weak)"
+      - "(speech|talking)\\s+(is\\s+)?(slurred|garbled|jumbled).*(arm|leg|weak|numb)"
+      - "(pale|cold|white|blue)\\s+(and\\s+)?(can'?t\\s+move|numb|no\\s+feeling)"
+      - "lost\\s+(all\\s+)?(feeling|function|movement|strength)\\s+in\\s+(my\\s+)?(arm|leg|hand|foot)"
+      # --- additional naturalistic ---
+      - "(leg|arm)\\s+(went|is)\\s+dead"
+      - "can'?t\\s+feel\\s+my\\s+(leg|arm)\\s+(at all|anymore|whatsoever)"
+      # --- sudden weakness patterns ---
+      - "(arm|leg|hand)\\s+(suddenly|just)\\s+(went\\s+)?(weak|limp|gave\\s+out)"
+      - "(sudden|suddenly).{0,15}(arm|leg|hand).{0,15}(weak|gave\\s+out|stopped\\s+working)"
+      # --- motor loss patterns ---
+      - "(can'?t|couldn'?t)\\s+(pick\\s+up|lift|hold|grip|squeeze|move|use).{0,15}(anything|things|my)"
+      - "(dropped|keep\\s+dropping|keeps\\s+dropping).{0,15}(everything|things|stuff)"
+      - "(arm|hand|leg|foot).{0,15}(won'?t|doesn'?t|isn'?t).{0,15}(work|move|respond|cooperate)"
+      # --- pins and needles / tingling ---
+      - "(pins\\s+and\\s+needles|tingling|prickling).{0,15}(all\\s+over|up|down|in).{0,15}(my|the)\\s+(arm|leg|hand|foot)"
+      - "(arm|leg|hand|foot).{0,15}(went|is|going).{0,15}(tingly|numb|asleep)"
+  medium:
+    phrases:
+      # --- original ---
+      - "lost feeling in my arm suddenly"
+      - "leg suddenly weak"
+      - "can't grip with my hand"
+      - "limb feels dead"
+      - "sudden weakness in one leg"
+      - "arm or leg not working"
+      # --- expanded naturalistic ---
+      - "my arm feels really weak"
+      - "having trouble gripping things"
+      - "my leg keeps giving way"
+      - "I keep dropping things"
+      - "my foot is dragging when I walk"
+      - "having difficulty walking all of a sudden"
+      - "tingling and weakness in my hand"
+      - "tingling and weakness in my arm"
+      - "tingling and weakness in my leg"
+      - "my limb feels heavy and won't work right"
+      - "arm feels like it weighs a ton"
+      - "leg feels like jelly"
+      - "having trouble lifting my arm"
+      - "my grip strength is gone"
+      - "foot drop started today"
+      - "dragging my foot when I walk"
+      - "slurred speech with arm weakness"
+      - "one hand feels clumsy and weak"
+      - "my leg buckles when I try to stand"
+      - "weakness came on pretty quickly"
+      - "trouble moving my fingers"
+      - "can't hold a cup in my hand"
+      - "my arm gave out carrying something"
+      - "pins and needles with weakness in arm"
+      - "leg not supporting my weight"
+      - "hand went tingly and now it is weak"
+      - "stumbling because my leg is weak"
+      - "balance is off and one side feels weak"
+      # --- MINIMIZER coverage ---
+      - "arm isn't cooperating like normal"
+      - "leg feels kind of off"
+      - "hand doesn't feel right"
+      - "arm feels a little different"
+      - "leg isn't quite right"
+      - "having trouble with my hand today"
+      - "arm just not working like it should"
+      # --- additional sudden weakness phrases ---
+      - "arm suddenly went weak"
+      - "leg suddenly went weak"
+      - "arm suddenly gave out"
+      - "leg suddenly gave out"
+      - "can't grip anything"
+      - "grip is gone"
+      - "can't hold things anymore"
+      - "lost strength in my arm"
+      - "lost strength in my leg"
+      - "arm went numb out of nowhere"
+      - "leg went numb out of nowhere"
+      - "can't feel my fingers"
+      - "can't feel my toes"
+      - "whole arm is numb"
+      - "whole leg is numb"
+      # --- minimizer patterns ---
+      - "arm feels a bit heavy"
+      - "leg feels a bit heavy"
+      - "arm is just a little numb"
+      - "leg is just a little numb"
+      - "hand is a little weak"
+      - "grip isn't as strong"
+      - "arm feels kind of dead"
+      - "leg feels kind of dead"
+      - "arm doesn't feel normal"
+      - "leg doesn't feel normal"
+    regex:
+      - "(arm|leg|hand|foot)\\s+(feels?|is|got|became|went|getting)\\s+(really\\s+)?(weak|heavy|tingly|numb)"
+      - "(trouble|difficulty|hard\\s+time|problem)\\s+(gripping|holding|lifting|walking|moving|standing)"
+      - "(dropping|can'?t\\s+hold|can'?t\\s+grip|can'?t\\s+grasp|couldn'?t\\s+hold)\\s+(things|objects|cup|glass|pot|mug|steady|tight)"
+      - "(leg|foot)\\s+(giving|gives|keeps\\s+giving)\\s+(out|way)"
+      - "(foot|leg)\\s+(is\\s+)?(dragging|drag)"
+      - "(tingling|pins\\s+and\\s+needles)\\s+(and|with)\\s+(weakness|weak)"
+      - "(weakness|weak)\\s+(came|started|began)\\s+(on\\s+)?(suddenly|quickly|today|fast)"
+      - "(arm|leg|hand)\\s+(gave|gives|giving)\\s+out"
+      - "(stumbling|tripping|falling|buckling)\\s+(because|due|from).*(weak|leg|foot)"
+      - "balance\\s+(is\\s+)?(off|bad|poor).*(weak|side|leg|arm)"
+      - "slurred\\s+speech\\s+(with|and)\\s+(arm|leg|weakness)"
+      - "(grip|hand).{0,15}(unreliable|giving\\s+out|not\\s+working|went\\s+weak)"
+      - "(wrist|hand|arm).{0,10}(drops|sort\\s+of\\s+drops|just\\s+drops)"
+      - "(can'?t|couldn'?t)\\s+(squeeze|grip|hold).{0,15}(hard|tight|steady|properly)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(arm|leg|hand|foot|limb).{0,20}(not right|feels? off|'s off|is off|seems? off|funny|weird|strange|different|acting up|not cooperating|not quite)"
+      - "(arm|leg|hand|foot).{0,20}(a bit|kind of|sort of|little|slightly).{0,15}(weak|numb|heavy|tingly|off)"
+      - "(clumsy|fumbl|dropping|butter.?fingers).{0,15}(today|lately|this morning|suddenly|all day)"
+      - "(hard|harder|having trouble|difficulty).{0,15}(opening|holding|gripping|walking|using|with).{0,15}(hand|arm|leg|door|jar|bottle)"
+      - "(arm|leg|hand).{0,15}(doesn'?t|isn'?t|not).{0,10}(feel|work|respond).{0,10}(right|normal|properly|the same)"
+      - "(arm|leg|hand|foot).{0,15}(feels?).{0,10}(different|weird|off|funny|wrong|not the same)"
+      # --- minimizer negation with deficit language ---
+      - "(can\\s+still|but\\s+I\\s+)?.{0,20}(arm|leg|hand|foot).{0,20}(heavy|weak|off|different)"
+      # --- vague time + deficit (confused/vague archetype) ---
+      - "(time\\s+gets|don'?t\\s+remember|mixed\\s+up).{0,30}(arm|leg|hand).{0,30}(heavy|off|weak)"
+    partials:
+      - "arm weakness"
+      - "leg weakness"
+      - "hand weakness"
+      - "foot drop"
+      - "grip weakness"
+      - "sudden tingling"
+      - "limb heaviness"
+  low:
+    partials:
+      # --- original ---
+      - "limb weakness"
+      - "sudden numbness"
+      - "paralysis"
+      - "limb deficit"
+      # --- expanded ---
+      - "hemiparesis"
+      - "hemiplegia"
+      - "paresthesia"
+      - "limb ischemia"
+      - "acute weakness"
+      - "motor deficit"
+      - "CVA"
+      - "TIA"
+      - "cerebrovascular accident"
+      - "transient ischemic attack"
+      - "acute limb ischemia"
+      - "vascular occlusion"
+      - "peripheral ischemia"
+      - "monoparesis"
+      - "focal weakness"
+      - "acute neurological deficit"
+      - "upper motor neuron"
+      - "lower motor neuron"
+      - "facial droop"
+
+negation_handling:
+  patterns:
+    # --- original ---
+    - "limbs are fine"
+    - "no weakness"
+    - "feeling normal in arms and legs"
+    # --- expanded ---
+    - "weakness from old injury"
+    - "chronic weakness"
+    - "known neuropathy"
+    - "weakness improving"
+    - "had this weakness for years"
+    - "weakness from my arthritis"
+    - "old stroke with residual weakness"
+    - "baseline weakness from prior injury"
+    - "neuropathy has been stable"
+    - "weakness is nothing new"
+    - "been weak since my surgery years ago"
+    - "no new weakness"
+    - "weakness is the same as usual"
+    - "numbness resolved"
+    - "can move all limbs normally"
+    - "strength is back to normal"
+    - "grip strength improving"
+    - "no loss of function"
+    - "tingling went away on its own"
+    - "weakness from not using it"
+    - "no acute deficit"
+    - "no focal weakness"
+    - "peripheral neuropathy stable"
+    - "weakness attributed to deconditioning"
+    - "PT says weakness is from disuse"
+    # --- R1 denial coverage ---
+    - "no arm weakness"
+    - "no leg weakness"
+    - "arms are fine"
+    - "legs are fine"
+    - "hands are fine"
+    - "feet are fine"
+    - "no numbness in arms"
+    - "no numbness in legs"
+    - "no tingling"
+    - "not weak"
+    - "not numb"
+    - "strength is fine"
+    - "can move everything fine"
+    - "no weakness in arms or legs"
+    - "arms and legs are fine"
+    - "arm is fine"
+    - "leg is fine"
+    - "hand is fine"
+    - "no arm problems"
+    - "no leg problems"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/airway_compromise/flows/clarify.yaml b/decision/taxonomy/airway_compromise/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..425ce8f8b80978c7062f86f6804615726b445a38
--- /dev/null
+++ b/decision/taxonomy/airway_compromise/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: airway_compromise
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: airway_compromise_clarify
+      goal: "Ask patient to describe their airway compromise symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - airway_compromise_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/airway_compromise/flows/escalate_r3.yaml b/decision/taxonomy/airway_compromise/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d647f800d377a99096b062f6aba89cbc8e152c18
--- /dev/null
+++ b/decision/taxonomy/airway_compromise/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: airway_compromise
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Inform patient this requires immediate clinical attention and they will be transferred"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/airway_compromise/flows/handoff.yaml b/decision/taxonomy/airway_compromise/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..45a7af4d3ea8371ec00430846380334721b1ff22
--- /dev/null
+++ b/decision/taxonomy/airway_compromise/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: airway_compromise
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: airway_compromise_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: airway_compromise_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/airway_compromise/rules.yaml b/decision/taxonomy/airway_compromise/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ee128b4f2551883d5bbd0ad10da2ff8ac7fa5d2d
--- /dev/null
+++ b/decision/taxonomy/airway_compromise/rules.yaml
@@ -0,0 +1,21 @@
+domain: airway_compromise
+target_risk_class: R3
+
+decision_rules:
+  - id: airway_compromise_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r3
+
+  - id: airway_compromise_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r3
+
+  - id: airway_compromise_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/airway_compromise/triggers.yaml b/decision/taxonomy/airway_compromise/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..12c4938cfe588665eed7654557bfe59e7e904e17
--- /dev/null
+++ b/decision/taxonomy/airway_compromise/triggers.yaml
@@ -0,0 +1,104 @@
+domain: airway_compromise
+priority: 97
+
+lexical_signals:
+  high:
+    phrases:
+      - "choking"
+      - "can't swallow"
+      - "something stuck in throat"
+      - "stridor"
+      - "airway blocked"
+      - "can't get air in"
+      - "throat closing up"
+      - "throat is closing"
+      - "throat feels tight"
+      - "throat is getting tight"
+      - "throat is swelling"
+    regex:
+      - "(choking|airway)\\s+(on|blocked|compromis)"
+      - "throat\\s+(closing|swelling|tight|narrowing)"
+      - "throat.{0,15}(tight|closing|swelling|narrow|block|squeez)"
+      - "(tight|closing|swelling|squeez).{0,15}(in\\s+)?(my\\s+)?throat"
+      - "(can'?t|hard(er)?\\s+to|difficult\\s+to)\\s+(swallow|get\\s+air|pull\\s+air)"
+      - "(hard|difficult|harder).{0,10}(to\\s+)?(swallow|pull\\s+air)"
+      # --- cyanosis ---
+      - "(lips?|face|fingers?|skin).{0,10}(turning|turned|is|are|look|looks|getting).{0,10}(blue|bluish|purple|gray|grey|cyanotic)"
+      - "(blue|bluish|purple|cyanotic).{0,15}(lips?|face|around (the )?mouth|fingers?)"
+      - "(purple|blue|dusky).{0,10}(around|near).{0,10}(mouth|lips?)"
+      # --- choking behaviors ---
+      - "(grabbing|clutching|holding|hands? on|reaching for).{0,10}(throat|neck)"
+      - "(can'?t|unable to|not able to).{0,10}(talk|speak|say anything|get words out)"
+      - "(gasping|gulping|fighting).{0,10}(for)?.{0,5}(air|breath)"
+      - "making.{0,10}(no sound|silent)"
+      # --- voice changes ---
+      - "voice.{0,15}(disappeared|gone|lost|hoarse|raspy|changed|different)"
+      - "(can barely|barely can).{0,10}(speak|talk|get words)"
+      - "(stridor|wheez|whistle).{0,15}(when|every time).{0,10}(breath|inhal)"
+      # --- witnessed events ---
+      - "(choking|choked).{0,15}(on|while eating).{0,15}(food|eating|meat|steak|chicken|bone|candy|pill)"
+      - "(something|food|pill|bone).{0,15}(stuck|lodged).{0,15}(in|down).{0,10}(throat|airway|windpipe)"
+      - "(swallowed|ate|inhaled).{0,15}(wrong way|down wrong|went down wrong)"
+  medium:
+    phrases:
+      - "difficulty swallowing and can't breathe"
+      - "throat feels blocked"
+      - "gagging and can't breathe"
+      - "food stuck in airway"
+      - "noisy breathing"
+      - "wheezing severely"
+      - "breathing weird"
+      - "harder to pull air in"
+      - "chest is tight and can't breathe"
+      - "throat feels like it's getting tight"
+      - "voice sounds weird"
+      - "voice is hoarse"
+      - "voice sounds muffled"
+      - "lips feel puffy"
+      - "high-pitched sound when I breathe"
+      - "high-pitched sound when I inhale"
+      - "the space is narrowing"
+    regex:
+      - "throat.{0,20}(block|weird|funny|strange|off)"
+      - "(noisy|loud|wheez|raspy|ragged).{0,10}breath"
+      - "(voice|speaking).{0,25}(weird|hoarse|raspy|strange|different|funny|muffled|thick)"
+      - "breath.{0,10}(weird|strange|noisy|loud|funny)"
+      - "(high.{0,5}pitched|whistl).{0,15}(sound|noise|when\\s+I\\s+(breath|inhal))"
+      - "(space|airway).{0,10}(narrowing|closing|getting\\s+smaller|shrinking)"
+      - "(lips?|tongue|face).{0,15}(puffy|swelling|swollen|bigger|tingly|blue|bluish|purple|cyanotic|discolored)"
+      # --- caregiver report ---
+      - "(they|he|she)\\s+(can'?t|is not|isn'?t)\\s+(breathe|breathing|getting air)"
+      - "(choking|turning)\\s+(and\\s+)?(blue|purple|gray|cyanotic)"
+      - "(drooling|can'?t swallow)\\s+(and\\s+)?(can'?t|not|hard to)\\s+(breathe|talk|speak)"
+      # --- from missed scenarios analysis ---
+      - "(wheez|wheeze|wheezing).{0,30}(worse|terrible|awful|severe|getting|bad)"
+      - "(lips?|mouth).{0,15}(look|are|turned|turning|seem).{0,15}(blue|bluish|purple|gray|cyanotic)"
+      - "(grab|clutch|hold|pulling|clawing).{0,15}(at\\s+)?(throat|neck)"
+      - "(can\\s+barely|barely\\s+can)\\s+(breathe|get air|talk|speak|get words)"
+      - "(labored|struggling|heaving|gasping|working hard).{0,15}(breath|to breathe|breathing)"
+      - "(awful|terrible|horrible|scary).{0,15}(sound|noise).{0,20}(breath|wheez)"
+      - "(straw|pinhole|narrow).{0,20}(breath|breathing|air)"
+      - "(chest|ribs?).{0,10}(heaving|working hard|retracting|pulling in)"
+  low:
+    partials:
+      - "stridor"
+      - "airway"
+      - "choking"
+      - "obstructed"
+      - "throat tight"
+      - "swallowing difficulty"
+
+negation_handling:
+  patterns:
+    - "not choking"
+    - "can swallow fine"
+    - "throat is clear"
+    - "airway is fine"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/anaphylaxis/flows/clarify.yaml b/decision/taxonomy/anaphylaxis/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..97425e214b3e7ba09563fee0b396daa889f6962e
--- /dev/null
+++ b/decision/taxonomy/anaphylaxis/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: anaphylaxis
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: anaphylaxis_clarify
+      goal: "Ask patient to describe their anaphylaxis symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - anaphylaxis_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/anaphylaxis/flows/escalate_r3.yaml b/decision/taxonomy/anaphylaxis/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3b8c72a08f3251e2c078fac8dc5cf5184486c32c
--- /dev/null
+++ b/decision/taxonomy/anaphylaxis/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: anaphylaxis
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Inform patient this requires immediate clinical attention and they will be transferred"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/anaphylaxis/flows/handoff.yaml b/decision/taxonomy/anaphylaxis/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e1704fb68f44ab6fd369e8da3928e5d24892f22e
--- /dev/null
+++ b/decision/taxonomy/anaphylaxis/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: anaphylaxis
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: anaphylaxis_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: anaphylaxis_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/anaphylaxis/flows/reassure_low_risk.yaml b/decision/taxonomy/anaphylaxis/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8b34930aa1cb2eec5d2a15a84df6bc09585ba2ff
--- /dev/null
+++ b/decision/taxonomy/anaphylaxis/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: anaphylaxis
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: anaphylaxis_reassure
+      goal: "Acknowledge the patient's concern about an allergic reaction, note that their care team will be informed for routine follow-up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/anaphylaxis/flows/safety_screen.yaml b/decision/taxonomy/anaphylaxis/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c711d07c8f67071c1e01cbf8327b5b5eaa31c7c6
--- /dev/null
+++ b/decision/taxonomy/anaphylaxis/flows/safety_screen.yaml
@@ -0,0 +1,54 @@
+flow_id: safety_screen
+type: screening
+domain: anaphylaxis
+
+required_slots:
+  - rash_hives
+  - tongue_lip_swelling
+  - breathing_difficulty_acute
+  - exposure_trigger
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: anaphylaxis_screen_step1
+      goal: "Determine whether the patient has visible allergic reaction signs"
+      tone: calm_urgent
+      must_include:
+        - "reaction"
+      must_ask:
+        - "Do you have any rash, hives, or skin changes right now?"
+        - "Is your tongue, lips, or throat feeling swollen?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - rash_hives
+      - tongue_lip_swelling
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: anaphylaxis_screen_step2
+      goal: "Screen for respiratory compromise and identify trigger"
+      tone: calm_urgent
+      must_include:
+        - "important"
+      must_ask:
+        - "Are you having any difficulty breathing right now?"
+        - "Did you eat anything new or get exposed to something unusual recently?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - breathing_difficulty_acute
+      - exposure_trigger
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_r3
diff --git a/decision/taxonomy/anaphylaxis/rules.yaml b/decision/taxonomy/anaphylaxis/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..982be7ad37e23cc8a0684900e4d911216de9d3b8
--- /dev/null
+++ b/decision/taxonomy/anaphylaxis/rules.yaml
@@ -0,0 +1,27 @@
+domain: anaphylaxis
+target_risk_class: R3
+
+decision_rules:
+  - id: anaphylaxis_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: anaphylaxis_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: anaphylaxis_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: anaphylaxis_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
diff --git a/decision/taxonomy/anaphylaxis/triggers.yaml b/decision/taxonomy/anaphylaxis/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c9e00472371f581922a5a8fb6206be27c8a973e5
--- /dev/null
+++ b/decision/taxonomy/anaphylaxis/triggers.yaml
@@ -0,0 +1,143 @@
+domain: anaphylaxis
+priority: 92
+
+lexical_signals:
+  high:
+    phrases:
+      - "throat is swelling shut"
+      - "can't breathe allergic reaction"
+      - "anaphylaxis"
+      - "tongue is swelling"
+      - "severe allergic reaction"
+      - "used my epipen"
+      - "whole body hives and can't breathe"
+      - "throat feels tight"
+      - "lips are swelling"
+      - "face is swelling"
+    regex:
+      - "(throat|tongue)\\s+(is\\s+)?swelling"
+      - "anaphyla"
+      - "(throat|face|lips|tongue).{0,15}(swell|puff|tight|clos)"
+      - "(allergic|allergy|reaction).{0,30}(throat|swell|breathing|breathe|hives)"
+      - "(hives|rash|itchy|blotch).{0,30}(throat|swell|breathing|breathe|tight)"
+      - "(can'?t|hard\\s+to|difficult).{0,10}(swallow|breathe).{0,20}(allerg|reaction|ate|food|shrimp|nut|peanut)"
+  medium:
+    phrases:
+      - "allergic reaction with swelling"
+      - "hives spreading everywhere"
+      - "difficulty swallowing after allergic reaction"
+      - "allergic reaction getting worse"
+      - "swelling face"
+      - "face feels hot and puffy"
+      - "itchy and throat tight"
+      - "harder to swallow"
+      - "voice sounds weird"
+      - "rash and my throat"
+      - "blotchy and itchy"
+      - "ate something and now throat"
+      # --- MINIMIZER coverage ---
+      - "voice sounds funny to me"
+      - "keep clearing my throat"
+      - "feels like I have to think about breathing"
+      - "red bumpy stuff on my arms"
+      - "skin is breaking out"
+      - "kind of shaky and weird"
+      - "stomach feels off after eating"
+    regex:
+      - "(ate|eaten|food|shrimp|nut|peanut|shellfish).{0,40}(throat|swell|hives|rash|itch|react)"
+      - "(throat|swell|hives|rash|itch|react).{0,40}(ate|eaten|food|shrimp|nut|peanut|shellfish)"
+      - "(face|skin).{0,15}(hot|puffy|swollen|blotchy|flushed)"
+      - "(hives|rash|itch|welt).{0,20}(spread|everywhere|worse|getting)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(voice|throat).{0,15}(funny|weird|off|different|strange|hoarse|scratchy|thick)"
+      - "(hard|harder|difficult|tough).{0,10}(to\\s+)?(breathe|breathing|swallow|catch).{0,10}(breath)?"
+      - "(red|bump|hive|welt|itch|rash|blotch).{0,15}(arm|body|skin|everywhere|spreading|neck|chest|stomach)"
+      - "\\b(shaky|dizzy|weird|funny)\\b.{0,25}\\b(ate|eat|eaten|eating|food|lunch|dinner|sting|stung|bitten)\\b"
+      - "\\b(ate|eat|eaten|eating|food|sting|stung|bitten)\\b.{0,25}\\b(shaky|dizzy|weird|funny|stomach|nausea|throw)\\b"
+      - "can'?t.{0,10}(take|get).{0,10}(deep|full).{0,10}breath"
+      - "(lip|face|tongue|eye).{0,15}(puffy|puff|swell|swollen|bigger|fat|tingle)"
+      - "(throat|voice).{0,15}(closing|tightening|getting tight|swelling|feels tight)"
+  low:
+    partials:
+      - "epipen"
+      - "anaphylaxis"
+
+negation_handling:
+  patterns:
+    - "no allergic reaction"
+    - "allergy under control"
+    - "reaction cleared up"
+    - "hives resolved"
+    - "hives went away"
+    - "mild allergic reaction"
+    - "no throat swelling"
+    - "breathing fine"
+    # --- R1 denial coverage ---
+    - "no hives"
+    - "no rash"
+    - "no swelling"
+    - "not swollen"
+    - "no itching"
+    - "not itchy"
+    - "no difficulty breathing"
+    - "no trouble breathing"
+    - "no allergic symptoms"
+    - "not having an allergic reaction"
+    - "no bumps"
+    - "no welts"
+    # --- mild medication side effect context ---
+    - "just a rash"
+    - "mild rash"
+    - "small rash"
+    - "a few blotches"
+    - "just itchy"
+    - "just some bumps"
+    - "little hives"
+    - "minor reaction"
+    - "mild reaction"
+    - "skin reaction"
+    - "just a skin thing"
+    - "not severe"
+    - "can breathe fine"
+    - "breathing is fine"
+    - "throat is fine"
+    - "no throat swelling"
+    - "swallowing fine"
+    - "can swallow fine"
+    - "no trouble swallowing"
+    - "face is fine"
+    - "no facial swelling"
+    - "just on my arms"
+    - "just on my skin"
+    - "topical only"
+    - "localized rash"
+    - "contact rash"
+    - "no wheezing"
+    - "started a new medication"
+    - "started a new antibiotic"
+    - "started a new blood pressure"
+    - "started a new prescription"
+    - "started taking"
+    - "since starting the new"
+    - "since I started the"
+    - "after the new medication"
+    - "after starting the"
+    - "side effect"
+    - "drug reaction"
+    - "medication side effect"
+    - "known side effect"
+    - "common reaction"
+    - "happened before with"
+    - "question about my medication"
+    - "question about my allergy"
+    - "allergy medication"
+    - "taking benadryl"
+    - "took an antihistamine"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/anticoagulant_hold_failure/flows/clarify.yaml b/decision/taxonomy/anticoagulant_hold_failure/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..2befd16b0218c933910f65c9e0dabf4f83032d97
--- /dev/null
+++ b/decision/taxonomy/anticoagulant_hold_failure/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: anticoagulant_hold_failure
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: anticoag_hold_clarify
+      goal: "Ask patient to describe their blood thinner concern more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - anticoag_hold_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/anticoagulant_hold_failure/flows/escalate_r2.yaml b/decision/taxonomy/anticoagulant_hold_failure/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7baa8d0c3c569c7bd3a9a6403d770e7ad810322c
--- /dev/null
+++ b/decision/taxonomy/anticoagulant_hold_failure/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: anticoagulant_hold_failure
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: anticoag_hold_r2_escalation_notice
+      goal: "Inform patient that a surgical nurse will follow up same day about their blood thinner status"
+      tone: calm_reassuring
+      must_include:
+        - "surgical nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: surgical_nurse
+    urgency: same_day
+    response_spec:
+      id: anticoag_hold_r2_handoff
+      goal: "Schedule same-day surgical nurse callback with blood thinner context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/anticoagulant_hold_failure/flows/escalate_r3.yaml b/decision/taxonomy/anticoagulant_hold_failure/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..2ab89f1bb092e4baaf5b612617a3d59df84ff683
--- /dev/null
+++ b/decision/taxonomy/anticoagulant_hold_failure/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: anticoagulant_hold_failure
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Instruct patient to call 911 immediately and inform them of nurse transfer"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/anticoagulant_hold_failure/flows/reassure_low_risk.yaml b/decision/taxonomy/anticoagulant_hold_failure/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..cf94c85c0f5328d104f7267f02f3d8ecd0989232
--- /dev/null
+++ b/decision/taxonomy/anticoagulant_hold_failure/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: anticoagulant_hold_failure
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: anticoag_hold_reassure
+      goal: "Acknowledge the patient followed their blood thinner hold instructions correctly and note their care team will be informed"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/anticoagulant_hold_failure/flows/safety_screen.yaml b/decision/taxonomy/anticoagulant_hold_failure/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c572c20c8e39a2df16e7c0c6757a72fd3860ce83
--- /dev/null
+++ b/decision/taxonomy/anticoagulant_hold_failure/flows/safety_screen.yaml
@@ -0,0 +1,52 @@
+flow_id: safety_screen
+type: screening
+domain: anticoagulant_hold_failure
+
+required_slots:
+  - anticoag_still_taking
+  - anticoag_last_dose
+  - surgery_date_aware
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: anticoag_hold_screen_step1
+      goal: "Determine whether the patient is still taking their anticoagulant and when the last dose was"
+      tone: calm_urgent
+      must_include:
+        - "blood thinner"
+      must_ask:
+        - "Are you still taking your blood thinner?"
+        - "When was your last dose?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - anticoag_still_taking
+      - anticoag_last_dose
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: anticoag_hold_screen_step2
+      goal: "Confirm the patient knows their surgery date and timing"
+      tone: calm_urgent
+      must_include:
+        - "surgery"
+      must_ask:
+        - "When is your surgery scheduled?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 1
+    collects:
+      - surgery_date_aware
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_r3: escalate_r3
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_r2
diff --git a/decision/taxonomy/anticoagulant_hold_failure/rules.yaml b/decision/taxonomy/anticoagulant_hold_failure/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e7bc77923e4f940eb58a461b5d8c1841cd6e3c8f
--- /dev/null
+++ b/decision/taxonomy/anticoagulant_hold_failure/rules.yaml
@@ -0,0 +1,33 @@
+domain: anticoagulant_hold_failure
+target_risk_class: R2
+
+decision_rules:
+  - id: anticoagulant_hold_failure_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: anticoagulant_hold_failure_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: anticoagulant_hold_failure_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: anticoagulant_hold_failure_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: anticoagulant_hold_failure_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/anticoagulant_hold_failure/triggers.yaml b/decision/taxonomy/anticoagulant_hold_failure/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..2b4990e96979a24abe3fa2cfb8c10ea941db68f6
--- /dev/null
+++ b/decision/taxonomy/anticoagulant_hold_failure/triggers.yaml
@@ -0,0 +1,101 @@
+domain: anticoagulant_hold_failure
+priority: 71
+
+lexical_signals:
+  high:
+    phrases:
+      - "still taking my warfarin"
+      - "forgot to stop blood thinner"
+      - "didn't stop my eliquis"
+      - "took my blood thinner this morning"
+      - "still on coumadin"
+      - "haven't stopped the blood thinner"
+      - "took xarelto today"
+      - "forgot about the blood thinner hold"
+      - "still taking my anticoagulant"
+      - "took my blood thinner yesterday too"
+      - "didn't realize I was supposed to stop"
+      - "nobody told me to stop the blood thinner"
+      - "been taking it every day including today"
+      - "took my warfarin last night"
+      - "took eliquis this morning before I remembered"
+      - "still on my blood thinner and surgery is tomorrow"
+      - "I forgot to hold the coumadin"
+      - "took pradaxa this morning"
+    regex:
+      - "(still|kept|continue|continu)\\s+(tak|on|us).{0,20}(warfarin|eliquis|xarelto|coumadin|pradaxa|blood\\s+thinner|anticoagul)"
+      - "(warfarin|eliquis|xarelto|coumadin|pradaxa|blood\\s+thinner).{0,25}(still|forgot|didn't\\s+stop|haven't\\s+stop|took|taking)"
+      - "(forgot|forget|didn't|did\\s+not|haven't).{0,20}(stop|hold|discontinue).{0,15}(warfarin|eliquis|xarelto|coumadin|pradaxa|blood\\s+thinner|anticoagul)"
+      - "took.{0,15}(warfarin|eliquis|xarelto|coumadin|pradaxa|blood\\s+thinner).{0,15}(this\\s+morning|today|last\\s+night|yesterday)"
+      - "(warfarin|eliquis|xarelto|coumadin|pradaxa|blood\\s+thinner).{0,15}(this\\s+morning|today|last\\s+night|yesterday)"
+      - "(?<!stopped )(?<!held )(?<!off )(blood\\s+thinner|anticoagul).{0,20}(before|prior).{0,10}(surgery|procedure|operation)"
+  medium:
+    phrases:
+      - "blood thinner question"
+      - "when do I stop my warfarin"
+      - "my blood thinner"
+      - "anticoagulant instructions"
+      - "when should I stop eliquis"
+      - "blood thinner and surgery"
+      - "question about my coumadin"
+      - "hold instructions for blood thinner"
+      - "confused about the blood thinner hold"
+      - "not sure when to stop the blood thinner"
+      - "blood thinner before my procedure"
+    partials:
+      - "warfarin"
+      - "eliquis"
+      - "xarelto"
+      - "coumadin"
+      - "pradaxa"
+      - "blood thinner"
+      - "anticoagulant hold"
+      - "blood thinner hold"
+  low:
+    partials:
+      - "thin blood"
+      - "anti-clotting"
+      - "blood medication"
+      - "clotting medication"
+
+negation_handling:
+  patterns:
+    - "stopped my blood thinner"
+    - "held my warfarin"
+    - "off the blood thinner"
+    - "stopped it as instructed"
+    - "haven't taken it since"
+    - "followed the hold instructions"
+    - "stopped taking my eliquis"
+    - "held the coumadin"
+    - "off the xarelto"
+    - "stopped the blood thinner as told"
+    - "last dose was five days ago"
+    - "stopped it a week ago"
+    - "held the anticoagulant"
+    - "followed the instructions to stop"
+    - "not on any blood thinners"
+    - "no blood thinners"
+    - "don't take blood thinners"
+    - "never been on blood thinners"
+    - "stopped warfarin last week"
+    - "off coumadin for five days"
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_on_medication: ["warfarin", "eliquis", "xarelto", "coumadin", "pradaxa"]
+      reason: "Patient actively on anticoagulant -- hold failure risk confirmed"
+    - when:
+        patient_on_medication_class: ["anticoagulant", "DOAC"]
+      reason: "Patient on anticoagulant class -- hold failure risk confirmed"
+  boost_to_medium:
+    - when:
+        medication_count_above: 10
+      reason: "Polypharmacy patient -- higher risk of medication management error"
+  suppress:
+    - when:
+        patient_on_medication: ["aspirin"]
+        patient_on_medication_class: ["antiplatelet"]
+      reason: "Patient on antiplatelet not anticoagulant -- hold failure not applicable"
diff --git a/decision/taxonomy/audit_c_positive/flows/audit_c_screen.yaml b/decision/taxonomy/audit_c_positive/flows/audit_c_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..746811d05294e75fc5071a03dd3af5e1511749c5
--- /dev/null
+++ b/decision/taxonomy/audit_c_positive/flows/audit_c_screen.yaml
@@ -0,0 +1,55 @@
+flow_id: audit_c_screen
+type: screening
+domain: audit_c_positive
+
+required_slots:
+  - alcohol_frequency
+  - alcohol_quantity
+  - alcohol_binge_frequency
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: audit_c_screen_step1
+      goal: "Ask about frequency of alcohol use in a conversational, non-judgmental way"
+      tone: warm_professional
+      must_include:
+        - "alcohol"
+      must_ask:
+        - "How often do you have a drink containing alcohol?"
+      must_not:
+        - "AUDIT"
+        - "screening tool"
+        - "alcoholic"
+        - "problem"
+      max_questions: 1
+    collects:
+      - alcohol_frequency
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: audit_c_screen_step2
+      goal: "Ask about typical quantity per drinking occasion and binge frequency"
+      tone: warm_professional
+      must_include:
+        - "drinks"
+      must_ask:
+        - "On a typical day when you do drink, how many drinks do you have?"
+        - "How often do you have six or more drinks on one occasion?"
+      must_not:
+        - "AUDIT"
+        - "score"
+        - "problem drinker"
+        - "alcoholic"
+      max_questions: 2
+    collects:
+      - alcohol_quantity
+      - alcohol_binge_frequency
+
+exit:
+  on_complete: evaluate_concern
+  on_concern: brief_intervention_referral
+  on_low_risk: brief_intervention_referral
+  on_unclear: brief_intervention_referral
diff --git a/decision/taxonomy/audit_c_positive/flows/brief_intervention_referral.yaml b/decision/taxonomy/audit_c_positive/flows/brief_intervention_referral.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ea4808943b5be93ce8d6a3a7c44196b92b473ded
--- /dev/null
+++ b/decision/taxonomy/audit_c_positive/flows/brief_intervention_referral.yaml
@@ -0,0 +1,25 @@
+flow_id: brief_intervention_referral
+type: resolution
+domain: audit_c_positive
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: audit_c_brief_intervention
+      goal: "Thank the patient for sharing and inform them their care team will have this information. Do NOT reveal any score or clinical interpretation."
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "thank you for sharing"
+      must_not:
+        - "score"
+        - "AUDIT"
+        - "alcoholic"
+        - "problem"
+        - "elevated"
+        - "positive"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/audit_c_positive/flows/clarify.yaml b/decision/taxonomy/audit_c_positive/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a3bc161b4055bd718ed7ca57d16f2d915da71a5f
--- /dev/null
+++ b/decision/taxonomy/audit_c_positive/flows/clarify.yaml
@@ -0,0 +1,26 @@
+flow_id: clarify
+type: clarification
+domain: audit_c_positive
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: audit_c_clarify
+      goal: "Ask the patient to tell more about their drinking habits in a non-judgmental way"
+      tone: warm_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "alcoholic"
+        - "problem"
+        - "AUDIT"
+      max_questions: 1
+    collects:
+      - audit_c_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/audit_c_positive/rules.yaml b/decision/taxonomy/audit_c_positive/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..29f1b209014db88790b00eba4ee39a109420e0aa
--- /dev/null
+++ b/decision/taxonomy/audit_c_positive/rules.yaml
@@ -0,0 +1,27 @@
+domain: audit_c_positive
+target_risk_class: R1
+
+decision_rules:
+  - id: audit_c_positive_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: audit_c_screen
+
+  - id: audit_c_positive_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: audit_c_screen
+
+  - id: audit_c_positive_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: audit_c_positive_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: brief_intervention_referral
diff --git a/decision/taxonomy/audit_c_positive/triggers.yaml b/decision/taxonomy/audit_c_positive/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d58c81ee03c5192a59dbad56dc6aacf52a24d523
--- /dev/null
+++ b/decision/taxonomy/audit_c_positive/triggers.yaml
@@ -0,0 +1,77 @@
+domain: audit_c_positive
+priority: 36
+
+lexical_signals:
+  high:
+    phrases:
+      - "drinking every day now"
+      - "several drinks a day"
+      - "can't stop drinking"
+      - "drinking more than I should"
+      - "drink a bottle of wine every night"
+      - "six or more drinks at a time"
+      - "binge drinking on weekends"
+      - "drinking has gotten out of control"
+      - "need a drink to get through the day"
+      - "finish a bottle of liquor in a day"
+      - "drinking from morning to night"
+      - "a twelve pack a day"
+      - "heavy drinking every night"
+      - "drink until I pass out"
+      - "blackout from drinking"
+      - "can't remember what happened after drinking"
+    regex:
+      - "(drink|drinking).{0,15}(every\\s+day|daily|all\\s+day|morning|constantly|heavily|more\\s+than)"
+      - "(several|multiple|many|six|seven|eight|nine|ten).{0,10}(drink|beer|glass|shot)s?.{0,10}(a\\s+day|daily|per\\s+day|each\\s+day)"
+      - "(can't|cannot)\\s+(stop|quit|control).{0,10}(drink|alcohol)"
+      - "(bottle|six\\s+pack|twelve\\s+pack|case).{0,10}(a\\s+day|every\\s+night|daily|each\\s+night)"
+      - "(binge|blackout|pass\\s+out).{0,10}(drink|drunk|alcohol)"
+  medium:
+    phrases:
+      - "drinking more lately"
+      - "a few drinks a day"
+      - "drink every day"
+      - "beer every night"
+      - "wine every evening"
+      - "more alcohol than usual"
+      - "having a couple drinks daily"
+      - "increased my drinking"
+      - "hard liquor most nights"
+      - "drinking has increased"
+      - "cocktails after work every day"
+      - "drink more than I used to"
+      - "a drink or two every night"
+    regex:
+      - "(drink|drinking).{0,15}(more|increased|lately|recently|too\\s+much)"
+      - "(beer|wine|liquor|alcohol|cocktail).{0,15}(every|each|most)\\s+(night|evening|day)"
+      - "(a\\s+few|couple|two|three).{0,10}(drink|beer|glass|shot)s?.{0,10}(a\\s+day|daily|every)"
+  low:
+    partials:
+      - "beer"
+      - "wine"
+      - "liquor"
+      - "drinking"
+      - "alcohol"
+      - "cocktail"
+
+negation_handling:
+  patterns:
+    - "don't drink"
+    - "not drinking"
+    - "stopped drinking"
+    - "quit drinking"
+    - "sober"
+    - "no alcohol"
+    - "don't drink alcohol"
+    - "gave up drinking"
+    - "haven't had a drink"
+    - "teetotaler"
+    - "don't touch alcohol"
+    - "cut back on drinking"
+    - "rarely drink"
+    - "only socially"
+    - "just one on occasion"
+    - "not much of a drinker"
+    - "never been a drinker"
+    - "alcohol free"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/behavioral_crisis/flows/clarify.yaml b/decision/taxonomy/behavioral_crisis/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..960b11a94424ebd22728e6842894a1524f968850
--- /dev/null
+++ b/decision/taxonomy/behavioral_crisis/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: behavioral_crisis
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: behavioral_crisis_clarify
+      goal: "Ask patient to describe their behavioral crisis symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - behavioral_crisis_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/behavioral_crisis/flows/escalate_r2.yaml b/decision/taxonomy/behavioral_crisis/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0a5657f0393a59f71ae85e9ec676fadb11ea230c
--- /dev/null
+++ b/decision/taxonomy/behavioral_crisis/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: behavioral_crisis
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/behavioral_crisis/flows/handoff.yaml b/decision/taxonomy/behavioral_crisis/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c679104b301b46147e22a5a350a568915b59fb5c
--- /dev/null
+++ b/decision/taxonomy/behavioral_crisis/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: behavioral_crisis
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: behavioral_crisis_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: behavioral_crisis_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/behavioral_crisis/flows/safety_screen.yaml b/decision/taxonomy/behavioral_crisis/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..10bcf166f55d2134ecb764612601a2d67d835562
--- /dev/null
+++ b/decision/taxonomy/behavioral_crisis/flows/safety_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: safety_screen
+type: screening
+domain: behavioral_crisis
+
+required_slots:
+  - behavior_description
+  - safety_risk
+  - triggers_identified
+  - support_available
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "behavior description"
+        - "safety risk"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - behavior_description
+      - safety_risk
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "triggers identified"
+        - "support available"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - triggers_identified
+      - support_available
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/decision/taxonomy/behavioral_crisis/rules.yaml b/decision/taxonomy/behavioral_crisis/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..205ffeb510dd3950c0aea346987df5b5e84923ec
--- /dev/null
+++ b/decision/taxonomy/behavioral_crisis/rules.yaml
@@ -0,0 +1,27 @@
+domain: behavioral_crisis
+target_risk_class: R2
+
+decision_rules:
+  - id: behavioral_crisis_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: behavioral_crisis_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: behavioral_crisis_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: behavioral_crisis_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/behavioral_crisis/triggers.yaml b/decision/taxonomy/behavioral_crisis/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e81c63674ca59068d954bcc4bc50c8219f4882a1
--- /dev/null
+++ b/decision/taxonomy/behavioral_crisis/triggers.yaml
@@ -0,0 +1,239 @@
+domain: behavioral_crisis
+priority: 63
+
+lexical_signals:
+  high:
+    phrases:
+      # --- original ---
+      - "completely out of control"
+      - "behavioral crisis"
+      - "agitated and won't calm down"
+      - "breaking things and screaming"
+      - "aggressive and scared"
+      - "psychiatric emergency"
+      # --- expanded naturalistic ---
+      - "acting violent"
+      - "threatening to hurt someone"
+      - "destroying things"
+      - "screaming and won't stop"
+      - "having a complete breakdown"
+      - "psychotic episode"
+      - "seeing things that aren't there"
+      - "hearing voices telling him to hurt people"
+      - "hearing voices telling her to hurt people"
+      - "agitated and aggressive"
+      - "combative and out of control"
+      - "tried to attack someone"
+      - "throwing things at people"
+      - "violent and uncontrollable"
+      - "threatening to harm himself"
+      - "threatening to harm herself"
+      - "danger to self or others"
+      - "in a full psychotic state"
+      - "hallucinating and violent"
+      - "manic and aggressive"
+    regex:
+      # --- original ---
+      - "behavioral\\s+crisis"
+      - "(psychiatric|mental\\s+health)\\s+emergency"
+      # --- expanded ---
+      - "(acting|becoming|getting|turned)\\s+(violent|aggressive|combative|hostile)"
+      - "threaten(ing|ed|s)?\\s+(to\\s+)?(hurt|harm|kill|attack|hit)"
+      - "(destroy|breaking|smashing|throwing)\\s+(things|furniture|objects|stuff)"
+      - "(screaming|yelling|shouting)\\s+(and\\s+)?(won'?t|can'?t|not)\\s+(stop|calm)"
+      - "(complete|total|full|mental)\\s+(breakdown|meltdown|psychotic)"
+      - "(psychotic|psychosis)\\s+(episode|break|state)"
+      - "(seeing|hearing)\\s+(things|voices|people)\\s+(that|who|which)\\s+(aren'?t|are\\s+not|don'?t)"
+      - "hearing\\s+voices\\s+(telling|commanding|saying|ordering)"
+      - "(agitated|aggressive|combative)\\s+(and\\s+)?(out\\s+of\\s+control|uncontrollable|violent|dangerous)"
+      - "danger(ous)?\\s+(to\\s+)?(self|himself|herself|others|people)"
+      - "(hallucinating|delusional)\\s+(and\\s+)?(violent|aggressive|dangerous|combative)"
+      - "(manic|frenzied)\\s+(and\\s+)?(aggressive|violent|out\\s+of\\s+control)"
+  medium:
+    phrases:
+      # --- original ---
+      - "very agitated"
+      - "can't calm down"
+      - "extremely anxious and acting out"
+      - "emotional crisis"
+      - "behavioral episode"
+      - "severe agitation"
+      # --- expanded naturalistic ---
+      - "extremely anxious"
+      - "having a panic attack"
+      - "confused and aggressive"
+      - "pacing and yelling"
+      - "refusing to cooperate"
+      - "not making any sense"
+      - "talking to people who aren't there"
+      - "very paranoid"
+      - "very disoriented and upset"
+      - "won't let anyone near"
+      - "becoming increasingly agitated"
+      - "getting more and more worked up"
+      - "lashing out at staff"
+      - "lashing out at family"
+      - "screaming at everyone"
+      - "very confused and combative"
+      - "pulling out their IV"
+      - "trying to leave against medical advice"
+      - "threatening to leave AMA"
+      - "cannot be redirected"
+      - "escalating behavior"
+      - "delusional and frightened"
+      - "paranoid and hiding"
+      - "extremely irritable and aggressive"
+      - "swinging at people"
+      - "cursing and throwing things"
+      - "erratic and unpredictable behavior"
+      - "sundowning and aggressive"
+      - "severely anxious and inconsolable"
+      # --- MINIMIZER coverage ---
+      - "he's just being difficult"
+      - "she gets like this sometimes"
+      - "it's not that bad, just a tantrum"
+      - "just a bit worked up"
+      - "acting out a little"
+      - "being a bit aggressive but nothing too bad"
+      - "just having a bad day"
+      - "a little agitated but I can handle it"
+      - "things got a bit heated"
+      # --- Caregiver downplaying patterns (R2 recall) ---
+      - "shouldn't be calling about this"
+      - "probably shouldn't be calling"
+      - "maybe I'm overreacting"
+      - "gets like this"
+      - "he gets like this"
+      - "she gets like this"
+      # --- Property damage patterns ---
+      - "broke something"
+      - "broke a hole in the wall"
+      - "threw things"
+      - "throwing things"
+      - "punched the wall"
+      - "punched a hole"
+      - "kicked the door"
+      - "smashed something"
+      - "damaged property"
+      # --- escalation / deterioration ---
+      - "getting worse by the minute"
+      - "behavior is escalating"
+      - "situation is deteriorating"
+      - "medications not helping"
+      - "can't redirect"
+      - "tried everything"
+      - "heading for the door"
+      - "hitting himself"
+      - "hitting herself"
+      - "banging head"
+      - "threw a plate"
+      - "smashed a glass"
+      # --- Phase 6: R2 recall expansion ---
+      - "behavior is escalating"
+      - "situation is deteriorating"
+      - "can't redirect"
+      - "tried everything"
+      - "hitting himself"
+      - "banging head"
+    regex:
+      - "(very|extremely|severely|increasingly)\\s+(agitated|anxious|paranoid|confused|irritable|upset)"
+      - "(can'?t|won'?t|unable\\s+to|not\\s+able\\s+to)\\s+(calm|settle|relax|cooperate|be\\s+redirected)"
+      - "(pacing|rocking|screaming|yelling|cursing)\\s+(and\\s+)?(yelling|screaming|won'?t|refusing)"
+      - "talking\\s+to\\s+(people|someone|things)\\s+(who|that)\\s+(aren'?t|are\\s+not|don'?t)"
+      - "(refusing|won'?t|will\\s+not)\\s+(cooperate|comply|listen|take|let)"
+      - "(confused|disoriented)\\s+(and\\s+)?(aggressive|combative|agitated|violent|upset)"
+      - "(pulling|ripping|yanking)\\s+(out|off)\\s+(IV|lines|tubes|monitor)"
+      - "(lashing|striking|swinging|hitting)\\s+(out\\s+)?(at\\s+)?(staff|nurse|family|people|everyone)"
+      - "(escalating|worsening|increasing)\\s+(behavior|agitation|aggression)"
+      - "(erratic|unpredictable|bizarre|irrational)\\s+(behavior|actions|conduct)"
+      - "sundowning\\s+(and\\s+)?(agitat|aggress|combative|confused)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(just|only).{0,10}(a\\s+)?(little|bit|being).{0,10}(difficult|worked up|agitated|aggressive|upset|angry|violent)"
+      - "(gets?\\s+like\\s+this|always\\s+does\\s+this|does\\s+this\\s+sometimes).{0,15}(it's|not|nothing)"
+      - "(not\\s+that\\s+bad|nothing\\s+too|can\\s+handle|I\\s+can\\s+manage).{0,20}(agitat|aggress|upset|angry|violent|tantrum)"
+      - "(things|it|situation).{0,10}(got|getting|a\\s+bit).{0,10}(heated|out of hand|intense|scary|worse|wild)"
+      # --- destructive acts ---
+      - "(threw|throwing|smashing|breaking)\\s+(a\\s+)?(plate|glass|chair|phone|things)"
+      # --- safety concern for others ---
+      - "(scared|worried|afraid)\\s+(for|about)\\s+(the\\s+)?(staff|other|family|patients|safety)"
+      # --- Phase 6: R2 recall expansion ---
+      - "(behavior|situation).{0,20}(escalating|deteriorating|getting worse|out of control)"
+      - "(can't|cannot|unable to).{0,15}(redirect|calm|control|manage).{0,10}(him|her|them)"
+      - "(hitting|banging|hurting).{0,15}(himself|herself|head|wall|self)"
+      - "(scared|worried|afraid).{0,20}(for|about).{0,15}(safety|staff|others|family)"
+    partials:
+      - "agitation"
+      - "combative behavior"
+      - "behavioral escalation"
+      - "paranoid behavior"
+      - "panic attack"
+      - "acute confusion with aggression"
+      - "delirium with agitation"
+  low:
+    partials:
+      # --- original ---
+      - "agitated"
+      - "behavioral issue"
+      - "crisis"
+      - "acting out"
+      # --- expanded ---
+      - "psychosis"
+      - "mania"
+      - "agitation"
+      - "delirium"
+      - "acute behavioral change"
+      - "behavioral emergency"
+      - "acute psychosis"
+      - "acute mania"
+      - "altered mental status"
+      - "psychiatric crisis"
+      - "combative"
+      - "violent behavior"
+      - "behavioral disturbance"
+      - "seclusion needed"
+      - "restraint"
+      - "involuntary hold"
+      - "danger to self"
+      - "danger to others"
+      - "5150 hold"
+
+negation_handling:
+  patterns:
+    # --- original ---
+    - "calmed down"
+    - "behavior improved"
+    - "no behavioral issues"
+    # --- expanded ---
+    - "panic attack resolved"
+    - "feeling better now"
+    - "settled down"
+    - "agitation improving"
+    - "calmer after medication"
+    - "responding to redirection"
+    - "no longer aggressive"
+    - "behavior returning to baseline"
+    - "de-escalated successfully"
+    - "patient cooperative now"
+    - "no current safety concerns"
+    - "no violent behavior"
+    - "anxiety improving"
+    - "resting comfortably now"
+    - "calm and oriented"
+    - "no psychiatric emergency"
+    - "behavioral episode has passed"
+    - "medication helped calm them down"
+    - "able to be redirected now"
+    - "no agitation at this time"
+    - "pleasant and cooperative"
+    - "mood has stabilized"
+    - "hallucinations resolved with medication"
+    - "no longer hearing voices"
+    - "paranoia has improved"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/caregiver_safety_concern/flows/clarify.yaml b/decision/taxonomy/caregiver_safety_concern/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4a2c640933f6abea8636ca2f5f8e57b50237da70
--- /dev/null
+++ b/decision/taxonomy/caregiver_safety_concern/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: caregiver_safety_concern
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: caregiver_safety_concern_clarify
+      goal: "Ask patient to describe their caregiver safety concern symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - caregiver_safety_concern_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/caregiver_safety_concern/flows/escalate_r1.yaml b/decision/taxonomy/caregiver_safety_concern/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e25e71313c6a7b13df03ab96615f1899c2ff959f
--- /dev/null
+++ b/decision/taxonomy/caregiver_safety_concern/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: caregiver_safety_concern
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/caregiver_safety_concern/flows/handoff.yaml b/decision/taxonomy/caregiver_safety_concern/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ebd33faad874a47c7a87bcd3ef11067e0f265850
--- /dev/null
+++ b/decision/taxonomy/caregiver_safety_concern/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: caregiver_safety_concern
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: caregiver_safety_concern_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: caregiver_safety_concern_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/caregiver_safety_concern/rules.yaml b/decision/taxonomy/caregiver_safety_concern/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7a8db4a3e68674f8889f70b6f9130b5d9450afd8
--- /dev/null
+++ b/decision/taxonomy/caregiver_safety_concern/rules.yaml
@@ -0,0 +1,21 @@
+domain: caregiver_safety_concern
+target_risk_class: R1
+
+decision_rules:
+  - id: caregiver_safety_concern_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r1
+
+  - id: caregiver_safety_concern_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r1
+
+  - id: caregiver_safety_concern_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/caregiver_safety_concern/triggers.yaml b/decision/taxonomy/caregiver_safety_concern/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1790acdc2193d2d06032fe4a74574d89a69ae922
--- /dev/null
+++ b/decision/taxonomy/caregiver_safety_concern/triggers.yaml
@@ -0,0 +1,51 @@
+domain: caregiver_safety_concern
+priority: 47
+
+lexical_signals:
+  high:
+    phrases:
+      - "worried about patient safety at home"
+      - "don't think they're safe alone"
+      - "caregiver concerned about safety"
+      - "not safe to be home alone"
+      - "afraid they'll fall or get hurt at home"
+      - "patient is unsafe at home"
+      - "can't leave them alone"
+      - "they keep falling at home"
+      - "I'm scared something will happen"
+      - "not capable of caring for themselves"
+      - "the home isn't safe for them"
+      - "I don't think they can manage alone"
+      - "worried they'll hurt themselves"
+    regex:
+      - "(worried|concerned|afraid|scared).*(safe|safety|fall|hurt)\\s*(at\\s+)?home"
+      - "(not|isn'?t|can'?t)\\s+(safe|manage|care).*home"
+      - "(can'?t|shouldn'?t)\\s+(leave|be left)\\s+(them|him|her)\\s+alone"
+      - "not\\s+(capable|able)\\s+.*\\s+(care|manage|alone)"
+  medium:
+    phrases:
+      - "concerned about their ability at home"
+      - "they seem unsafe on their own"
+      - "worried about them being alone"
+      - "caregiver has concerns about safety"
+      - "don't feel comfortable leaving them alone"
+      - "struggling to take care of them"
+      - "need more help at home"
+      - "overwhelmed as a caregiver"
+      - "they can't do things on their own"
+      - "not sure they're safe"
+      - "worried about leaving them"
+  low:
+    partials:
+      - "safety concern"
+      - "home safety"
+      - "unsafe at home"
+      - "caregiver worry"
+      - "can't manage alone"
+
+negation_handling:
+  patterns:
+    - "safe at home"
+    - "doing well at home"
+    - "no safety concerns"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/chest_pain/flows/clarify.yaml b/decision/taxonomy/chest_pain/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..866e87b3762ad30cb0db8040a6bb0ed4173a3516
--- /dev/null
+++ b/decision/taxonomy/chest_pain/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: chest_pain
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: chest_pain_clarify
+      goal: "Ask patient to describe their chest-related symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 2
+    collects:
+      - chest_pain_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/chest_pain/flows/escalate_r2.yaml b/decision/taxonomy/chest_pain/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e7c90e9ee922d01fd777342696e811bafbf85655
--- /dev/null
+++ b/decision/taxonomy/chest_pain/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: chest_pain
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up soon about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "emergency"
+        - "heart attack"
+        - "diagnos"
+        - "don't worry"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: soon
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/chest_pain/flows/escalate_r3.yaml b/decision/taxonomy/chest_pain/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c83fb2f6bc000109759cabaf219968707cc4260a
--- /dev/null
+++ b/decision/taxonomy/chest_pain/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: chest_pain
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Inform patient this requires immediate clinical attention and they will be transferred"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "heart attack"
+        - "don't worry"
+        - "diagnos"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/chest_pain/flows/handoff.yaml b/decision/taxonomy/chest_pain/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7345f567137f66837a8c64d0c227ac0d48ebd4ff
--- /dev/null
+++ b/decision/taxonomy/chest_pain/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: chest_pain
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: chest_pain_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: chest_pain_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/chest_pain/flows/reassure_low_risk.yaml b/decision/taxonomy/chest_pain/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3b02c7612135047170c5a613ff05e62b905dd6ad
--- /dev/null
+++ b/decision/taxonomy/chest_pain/flows/reassure_low_risk.yaml
@@ -0,0 +1,23 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: chest_pain
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: chest_pain_low_risk_reassure
+      goal: "Reassure patient with low-risk chest symptoms and provide guidance"
+      tone: warm_professional
+      must_include:
+        - "glad"
+        - "symptoms"
+      must_ask: []
+      must_not:
+        - "nothing wrong"
+        - "diagnos"
+        - "guarantee"
+      max_questions: 1
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/chest_pain/flows/safety_screen.yaml b/decision/taxonomy/chest_pain/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9918409e3696222bd4e78a7f62f6b4292b76cdf0
--- /dev/null
+++ b/decision/taxonomy/chest_pain/flows/safety_screen.yaml
@@ -0,0 +1,54 @@
+flow_id: safety_screen
+type: screening
+domain: chest_pain
+
+required_slots:
+  - chest_pain_onset
+  - chest_pain_severity
+  - shortness_of_breath
+  - syncope_or_dizziness
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_onset
+      goal: "Determine when chest pain started and its severity"
+      tone: calm_urgent
+      must_include:
+        - "when"
+        - "pain"
+      must_ask:
+        - "chest pain start"
+        - "how severe"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - chest_pain_onset
+      - chest_pain_severity
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_associated
+      goal: "Screen for associated dangerous symptoms"
+      tone: calm_urgent
+      must_include:
+        - "breathing"
+      must_ask:
+        - "shortness of breath"
+        - "dizzy or lightheaded"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - shortness_of_breath
+      - syncope_or_dizziness
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_unclear: escalate_r3
diff --git a/decision/taxonomy/chest_pain/rules.yaml b/decision/taxonomy/chest_pain/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..06b6ca61b263c86e9fe3a7dd4752068384efaff4
--- /dev/null
+++ b/decision/taxonomy/chest_pain/rules.yaml
@@ -0,0 +1,35 @@
+domain: chest_pain
+target_risk_class: R3
+
+decision_rules:
+  # Confidence-based rules for initial triage (from nominations)
+  - id: chest_pain_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: chest_pain_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: chest_pain_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  # Risk-based rules (used after risk evaluation)
+  - id: chest_pain_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: chest_pain_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/chest_pain/triggers.yaml b/decision/taxonomy/chest_pain/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d90c30478912d8c38c915b124487e1ad778247a5
--- /dev/null
+++ b/decision/taxonomy/chest_pain/triggers.yaml
@@ -0,0 +1,275 @@
+domain: chest_pain
+priority: 100
+
+lexical_signals:
+  high:
+    phrases:
+      - "chest pain"
+      - "chest pressure"
+      - "chest tightness"
+      - "heart attack"
+      - "crushing pain in my chest"
+      - "chest hurts"
+      - "pain in my chest"
+      - "tightness in my chest"
+      - "pressure in my chest"
+      - "heavy feeling in my chest"
+      - "my chest is killing me"
+      - "sharp pain in my chest"
+      - "stabbing pain in my chest"
+      - "squeezing feeling in my chest"
+      - "burning in my chest"
+      - "chest feels like it is being crushed"
+      - "feels like someone is sitting on my chest"
+      - "woke up with chest pain"
+      - "chest pain won't go away"
+      - "severe chest pain"
+      - "horrible pain in my chest"
+      - "chest pain and shortness of breath"
+      - "chest pain going down my arm"
+      - "I think I am having a heart attack"
+      - "feels like my heart is being squeezed"
+    regex:
+      - "chest\\s+(pain|pressure|tight|heavy|hurt|squeez|crush)"
+      - "(pain|pressure|tight|heavy|hurt|squeez|crush|ache|discomfort).{0,25}(in\\s+)?(my\\s+)?chest"
+      - "chest.{0,25}(pain|pressure|tight|heavy|hurt|squeez|crush|ache)"
+      - "(someone|something).{0,20}(sitting|pressing|pushing).{0,20}(on\\s+)?(my\\s+)?chest"
+      - "chest.{0,15}(feels?|is).{0,10}(heavy|tight|weird|funny|off|strange|wrong|bad|awful)"
+      - "chest.{0,10}(is\\s+)?kill(ing|s)\\s+me"
+      - "(sharp|stabbing|burning|searing|tearing).{0,15}(pain|feeling).{0,15}(in\\s+)?(my\\s+)?chest"
+      - "chest.{0,15}(won[']?t|doesn[']?t|isn[']?t).{0,10}(go away|stop|let up|ease)"
+      - "(woke|wake).{0,10}up.{0,15}chest\\s+(pain|hurt|pressure|tight)"
+      - "having\\s+a\\s+heart\\s+attack"
+      - "think.{0,10}(heart\\s+attack|cardiac)"
+      - "chest.{0,10}(and|with).{0,10}(short|can[']?t\\s+breath|hard\\s+to\\s+breath)"
+      - "horrible.{0,10}(pain|feeling).{0,10}(in\\s+)?(my\\s+)?chest"
+      - "chest\\s+(thing|stuff|issue|problem).{0,15}(heavy|tight|squeez|crush|pressure|pain|hurt|ache|bad)"
+      - "(rub|clutch|grab|hold|grip)(b?ing|bed|s)?.{0,10}(his|her|my|the)?\\s*chest"
+      - "chest.{0,10}(rub|clutch|grab|hold|grip)"
+  medium:
+    phrases:
+      - "hurts when I breathe"
+      - "pain in my left arm"
+      - "pain radiating"
+      - "sweating and chest feels weird"
+      - "chest feels weird"
+      - "chest feels kind of tight"
+      - "chest feels kinda weird"
+      - "heart is racing and chest hurts"
+      - "feels like an elephant on my chest"
+      - "hurts right here in the middle of my chest"
+      - "got this ache in my chest"
+      - "my chest keeps hurting on and off"
+      - "every time I take a deep breath my chest hurts"
+      - "left side of my chest is aching"
+      - "woke up and my chest felt tight"
+      - "jaw hurts and I feel pressure in my chest"
+      - "arm went numb and my chest feels funny"
+      - "nauseous and my chest hurts"
+      - "sweating for no reason and my chest feels heavy"
+      - "short of breath and my chest is tight"
+      - "I got dizzy and then my chest started hurting"
+      - "it comes and goes but my chest keeps aching"
+      - "chest has been bothering me all day"
+      - "something does not feel right in my chest"
+      - "my heart feels like it is fluttering and my chest hurts"
+      - "dull ache in the center of my chest"
+      - "band around my chest"
+      - "feels like a band around my chest"
+      - "chest pain after walking up the stairs"
+      - "chest started hurting during exercise"
+      - "rubbing his chest"
+      - "rubbing her chest"
+      - "rubbing my chest"
+      - "holding his chest"
+      - "grabbing his chest"
+      - "clutching his chest"
+      - "chest feels kinda tight"
+    regex:
+      - "(left\\s+arm|jaw|shoulder).{0,20}(pain|numb|tingle|ache|hurt)"
+      - "(pain|ache|hurt).{0,20}(radiat|spread|shoot|going).{0,15}(arm|shoulder|jaw|back|neck)"
+      - "(sweat|nausea|diaphores).{0,30}chest"
+      - "chest.{0,30}(sweat|nausea|diaphores)"
+      - "(left\\s+side|center|middle).{0,15}(of\\s+)?(my\\s+)?chest.{0,15}(ach|hurt|pain|bother)"
+      - "chest.{0,15}(bother|nag|bug).{0,5}(ing|ed|s)\\s+me"
+      - "(deep\\s+breath|breath\\s+in|inhale).{0,20}(chest|hurt|pain|ache)"
+      - "chest.{0,10}(on\\s+and\\s+off|come.{0,5}and\\s+go)"
+      - "(dizzy|lightheaded|faint).{0,20}chest"
+      - "chest.{0,20}(dizzy|lightheaded|faint)"
+      - "(short\\s+of\\s+breath|breathless|can[']?t\\s+catch).{0,20}chest"
+      - "heart.{0,10}(flutter|skip|race|pound).{0,15}chest"
+      - "(band|belt|strap).{0,10}(around|across).{0,10}chest"
+      - "dull.{0,5}(ache|pain).{0,10}(in\\s+)?(my\\s+)?chest"
+      - "chest.{0,15}(start|began|begin).{0,15}(hurt|ach|bother)"
+      - "(walk|stair|exert|exercis|exertion).{0,20}chest\\s+(pain|hurt|tight|pressure)"
+      - "chest.{0,20}(walk|stair|exert|exercis)"
+      - "(nauseous|throwing\\s+up|vomit).{0,20}chest"
+      - "(arm|shoulder).{0,10}(went|go|is|feel).{0,5}(numb|tingle)"
+      - "(rub|clutch|grab|hold)(b?ing|bed|s)?.{0,15}(his|her|my|the)?\\s*chest"
+      - "(looks?|looking)\\s+(pale|gray|grey|ashen|sweaty|clammy).{0,30}chest"
+    partials:
+      - "sternum"
+      - "angina"
+  low:
+    phrases:
+      - "feels funny in my chest"
+      - "something is off in my chest"
+      - "my chest has been acting up"
+      - "got a twinge in my chest"
+      - "a little discomfort in my chest area"
+    partials:
+      - "angina"
+      - "chest discomfort"
+      - "twinge"
+      - "chest area"
+      - "heart area"
+      - "breastbone"
+      - "chest thing"
+      - "chest stuff"
+
+negation_handling:
+  patterns:
+    - "no chest pain"
+    - "not having chest pain"
+    - "don't have chest pain"
+    - "no pain in my chest"
+    - "chest is fine"
+    - "no chest problems"
+    - "chest pain resolved"
+    - "chest pain gone"
+    - "reproducible"
+    - "when i press"
+    - "when i push on"
+    - "when i twist"
+    - "when i stretch"
+    - "when i rotate"
+    - "worse with movement"
+    - "worse with certain movements"
+    - "positional"
+    - "localized ache"
+    - "comes and goes with"
+    - "costochondritis"
+    - "musculoskeletal"
+    - "no crushing"
+    - "not cardiac"
+    - "chest pain is gone now"
+    - "chest pain went away"
+    - "chest does not hurt anymore"
+    - "chest feels fine now"
+    - "no tightness"
+    - "no pressure in my chest"
+    - "chest pain only when I press on it"
+    - "hurts only when I move a certain way"
+    - "pain goes away when I rest"
+    - "just heartburn"
+    - "it was just gas"
+    - "doctor said it was muscular"
+    - "already evaluated for chest pain"
+    - "stress related"
+    - "anxiety chest tightness"
+    - "panic attack"
+    - "when i poke"
+    - "only when i press"
+    - "only with movement"
+    - "tender to touch"
+    - "sore to touch"
+    - "hurts when i press on it"
+    - "goes away if i stop"
+    # --- screening denial coverage ---
+    - "no chest pain or"
+    - "no chest pain and no"
+    - "no chest pain like"
+    - "none of that"
+    - "not having any chest"
+    - "no pain no pressure"
+    - "chest feels normal"
+    - "no tightness in my chest"
+    - "no heaviness in my chest"
+    - "chest is not hurting"
+    - "no issues with my chest"
+    # --- medication/question context (reproducible_chest_discomfort R1) ---
+    - "chest pain medication"
+    - "medication for my chest"
+    - "medication for chest pain"
+    - "asking about my angina"
+    - "question about nitroglycerin"
+    - "nitroglycerin timing"
+    - "nitroglycerin schedule"
+    - "when to take my nitroglycerin"
+    - "stable angina"
+    - "my angina medication"
+    - "angina is stable"
+    - "managing my angina"
+    - "managing my chest"
+    - "my usual chest"
+    - "my regular chest"
+    - "my known chest"
+    - "predictable chest"
+    - "been managing this"
+    - "refill for chest"
+    - "chest pain is controlled"
+    - "on medication for my chest"
+    # --- musculoskeletal/reproducible context ---
+    - "chest wall"
+    - "chest wall pain"
+    - "same spot every time"
+    - "same exact spot"
+    - "can reproduce it"
+    - "can make it happen"
+    - "I can trigger it"
+    - "ice helps"
+    - "nsaid"
+    - "ibuprofen helps"
+    - "naproxen helps"
+    - "anti-inflammatory helps"
+    - "started after lifting"
+    - "started after carrying"
+    - "started after moving"
+    - "rib injury"
+    - "bruised rib"
+    - "strained muscle"
+    - "muscle strain"
+    - "physical therapy for my chest"
+    - "exercises for my chest"
+    - "stretching helps"
+    - "chest exercises"
+    - "the spot where it hurts"
+    - "only hurts when I touch"
+    - "only hurts when I push"
+    - "sharp when I twist"
+    - "sharp when I turn"
+    - "popping in my chest"
+    - "clicking in my chest"
+    # --- historical context (FDA-safe: keyword detection) ---
+    - "years ago"
+    - "in the past"
+    - "had this before"
+    - "history of chest"
+    - "used to have chest"
+    - "back when I had"
+    - "previously had"
+    - "past chest pain"
+    - "old chest pain"
+    # --- experiencer context (FDA-safe: keyword detection) ---
+    - "my mother had"
+    - "my father had"
+    - "my mom had"
+    - "my dad had"
+    - "my grandmother had"
+    - "my grandfather had"
+    - "asking for a friend"
+    - "someone I know"
+    - "my spouse has"
+    - "my wife has"
+    - "my husband has"
+    # --- administrative context (removed overly broad patterns ---
+    # NOTE: "schedule an appointment" etc. removed because they suppress
+    # real emergencies like "schedule an appointment, also having chest pain".
+    # For R3 domains, false positive escalation is safer than missing.
+    - "routine checkup for chest"
+    - "annual physical"
+    - "wellness visit"
+  # Changed to 'suppress' for R1 false escalation reduction.
+  # Reproducible/positional/musculoskeletal context should suppress chest_pain domain
+  # to prevent false escalation on R1 reproducible_chest_discomfort scenarios.
+  action: downgrade_confidence
diff --git a/decision/taxonomy/cognitive_concern/flows/clarify.yaml b/decision/taxonomy/cognitive_concern/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f14db896063c84d7d4052909dae499c242c7d242
--- /dev/null
+++ b/decision/taxonomy/cognitive_concern/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: cognitive_concern
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: cognitive_concern_clarify
+      goal: "Ask patient to describe their memory or thinking concerns in more detail"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "dementia"
+      max_questions: 1
+    collects:
+      - cognitive_concern_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/cognitive_concern/flows/concern_assessment.yaml b/decision/taxonomy/cognitive_concern/flows/concern_assessment.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1f1222f8d7340662144b34870a9e15ae684045d1
--- /dev/null
+++ b/decision/taxonomy/cognitive_concern/flows/concern_assessment.yaml
@@ -0,0 +1,53 @@
+flow_id: concern_assessment
+type: assessment
+domain: cognitive_concern
+
+required_slots:
+  - cognitive_severity
+  - cognitive_duration
+  - daily_impact
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: cognitive_concern_assess_step1
+      goal: "Understand the severity and duration of the patient's memory or confusion issues"
+      tone: warm_empathetic
+      must_include:
+        - "understand"
+      must_ask:
+        - "Can you tell me more about the memory or thinking difficulties you've been having?"
+        - "How long has this been going on?"
+      must_not:
+        - "dementia"
+        - "Alzheimer"
+        - "losing your mind"
+      max_questions: 2
+    collects:
+      - cognitive_severity
+      - cognitive_duration
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: cognitive_concern_assess_step2
+      goal: "Assess impact on daily activities and whether the patient has support"
+      tone: warm_empathetic
+      must_include:
+        - "daily life"
+      must_ask:
+        - "Has this affected your ability to manage daily tasks like cooking, medications, or getting around?"
+      must_not:
+        - "dementia"
+        - "can't live alone"
+        - "nursing home"
+      max_questions: 1
+    collects:
+      - daily_impact
+
+exit:
+  on_complete: evaluate_concern
+  on_concern: handoff
+  on_low_risk: reassure_low_risk
+  on_unclear: handoff
diff --git a/decision/taxonomy/cognitive_concern/flows/reassure_low_risk.yaml b/decision/taxonomy/cognitive_concern/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e3ead486e94fa9463792b5a2a93c260aceca580e
--- /dev/null
+++ b/decision/taxonomy/cognitive_concern/flows/reassure_low_risk.yaml
@@ -0,0 +1,22 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: cognitive_concern
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: cognitive_concern_reassure
+      goal: "Acknowledge the patient's concerns about memory, note that mild changes can be normal, and ensure their care team will be informed"
+      tone: warm_empathetic
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "nothing to worry about"
+        - "dementia"
+        - "normal for your age"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/cognitive_concern/rules.yaml b/decision/taxonomy/cognitive_concern/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..89798123b83faf2173854f1e02c4dc4c2641b173
--- /dev/null
+++ b/decision/taxonomy/cognitive_concern/rules.yaml
@@ -0,0 +1,27 @@
+domain: cognitive_concern
+target_risk_class: R1
+
+decision_rules:
+  - id: cognitive_concern_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: concern_assessment
+
+  - id: cognitive_concern_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: concern_assessment
+
+  - id: cognitive_concern_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: cognitive_concern_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/cognitive_concern/triggers.yaml b/decision/taxonomy/cognitive_concern/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a4cbf1ef12745653bacf733e4722bc9467139c9c
--- /dev/null
+++ b/decision/taxonomy/cognitive_concern/triggers.yaml
@@ -0,0 +1,70 @@
+domain: cognitive_concern
+priority: 35
+
+lexical_signals:
+  high:
+    phrases:
+      - "can't remember anything"
+      - "getting lost in my own house"
+      - "forgot where I am"
+      - "don't know what day it is"
+      - "memory is getting really bad"
+      - "keep forgetting my medications"
+      - "getting confused all the time"
+      - "can't remember my doctor's name"
+      - "lost and confused"
+      - "don't recognize people"
+      - "forgetting how to do things"
+      - "can't remember how to get home"
+      - "memory is much worse"
+      - "confused about where I am"
+      - "keep getting lost"
+    regex:
+      - "(can't|cannot|unable\\s+to)\\s+remember.{0,20}(anything|names|where|what|how)"
+      - "(getting|keep|always)\\s+(lost|confused|disoriented).{0,15}(house|home|neighborhood|familiar)"
+      - "memory.{0,15}(really|much|significantly|noticeably).{0,10}(bad|worse|declining|poor)"
+      - "(forget|forgot|forgetting).{0,15}(medication|medicine|pills|appointments|people|names)"
+  medium:
+    phrases:
+      - "memory issues"
+      - "getting confused"
+      - "forgetting things"
+      - "can't remember"
+      - "trouble remembering"
+      - "mind is foggy"
+      - "having trouble thinking"
+      - "memory isn't what it used to be"
+      - "forgetful lately"
+      - "confused sometimes"
+      - "trouble concentrating"
+      - "brain fog"
+      - "losing my train of thought"
+    regex:
+      - "(memory|remember).{0,15}(issue|problem|trouble|difficult|concern|worry)"
+      - "(confused|confusion|forgetful).{0,10}(lately|recently|sometimes|often)"
+      - "(trouble|difficulty|hard\\s+time).{0,10}(remember|thinking|concentrat)"
+  low:
+    partials:
+      - "forgetful"
+      - "memory"
+      - "confused"
+      - "foggy thinking"
+      - "scatterbrained"
+
+negation_handling:
+  patterns:
+    - "memory is fine"
+    - "no memory issues"
+    - "not confused"
+    - "thinking clearly"
+    - "sharp as a tack"
+    - "no trouble remembering"
+    - "memory is good"
+    - "not forgetful"
+    - "mind is clear"
+    - "no confusion"
+    - "remembering everything fine"
+    - "thinking is clear"
+    - "not having memory problems"
+    - "brain is working fine"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/dka_hhs/flows/clarify.yaml b/decision/taxonomy/dka_hhs/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f95d2e9743bcad06399303ba6f889e6c2b389d12
--- /dev/null
+++ b/decision/taxonomy/dka_hhs/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: dka_hhs
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: dka_hhs_clarify
+      goal: "Ask patient to describe their dka hhs symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - dka_hhs_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/dka_hhs/flows/escalate_r2.yaml b/decision/taxonomy/dka_hhs/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..513e2ab75fc888d65d191237f3347fc4c74db937
--- /dev/null
+++ b/decision/taxonomy/dka_hhs/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: dka_hhs
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will be connected to discuss urgent glucose concerns"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "connect"
+        - "important"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: urgent
+    response_spec:
+      id: r2_handoff
+      goal: "Warm transfer to nurse with context summary"
+      tone: professional
+      must_include:
+        - "connecting"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/dka_hhs/flows/escalate_r3.yaml b/decision/taxonomy/dka_hhs/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..72b7d27b1291c33ed6781c43be05be089bdd31aa
--- /dev/null
+++ b/decision/taxonomy/dka_hhs/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: dka_hhs
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Inform patient this requires immediate clinical attention and they will be transferred"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/dka_hhs/flows/handoff.yaml b/decision/taxonomy/dka_hhs/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..945bd4fb41ab5efb15827bcdabdfff76ee8dc1a1
--- /dev/null
+++ b/decision/taxonomy/dka_hhs/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: dka_hhs
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: dka_hhs_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: dka_hhs_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/dka_hhs/flows/reassure_low_risk.yaml b/decision/taxonomy/dka_hhs/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6b0cbec00eff664c2a2cef10b1cfeede782d9131
--- /dev/null
+++ b/decision/taxonomy/dka_hhs/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: dka_hhs
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: dka_hhs_reassure
+      goal: "Acknowledge the patient's concern about blood sugar, note that their care team will be informed for routine follow-up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/dka_hhs/flows/safety_screen.yaml b/decision/taxonomy/dka_hhs/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ebbd2dec08d8e2b007b1c8c6be604141f4ee37cd
--- /dev/null
+++ b/decision/taxonomy/dka_hhs/flows/safety_screen.yaml
@@ -0,0 +1,57 @@
+flow_id: safety_screen
+type: screening
+domain: dka_hhs
+
+required_slots:
+  - nausea_vomiting
+  - confusion_status
+  - ketone_symptoms
+  - abdominal_pain
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: dka_hhs_screen_step1
+      goal: "Determine whether the patient is experiencing acute GI symptoms associated with DKA"
+      tone: calm_urgent
+      must_include:
+        - "blood sugar"
+      must_ask:
+        - "Are you experiencing any nausea or vomiting?"
+        - "Any abdominal pain or stomach cramps?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - nausea_vomiting
+      - abdominal_pain
+      - glucose_reading_mg_dl
+      - glucose_level_bucket
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: dka_hhs_screen_step2
+      goal: "Screen for neurological and metabolic danger signals of DKA/HHS"
+      tone: calm_urgent
+      must_include:
+        - "important"
+      must_ask:
+        - "Are you feeling confused or having trouble thinking clearly?"
+        - "Have you noticed any fruity smell on your breath or unusual thirst?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - confusion_status
+      - ketone_symptoms
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_r2: escalate_r2
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_r3
diff --git a/decision/taxonomy/dka_hhs/rules.yaml b/decision/taxonomy/dka_hhs/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b93b8d833a8f53c121b040035528c3f3c22ebaae
--- /dev/null
+++ b/decision/taxonomy/dka_hhs/rules.yaml
@@ -0,0 +1,33 @@
+domain: dka_hhs
+target_risk_class: R3
+
+decision_rules:
+  - id: dka_hhs_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: dka_hhs_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: dka_hhs_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: dka_hhs_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: dka_hhs_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/dka_hhs/triggers.yaml b/decision/taxonomy/dka_hhs/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..2e3ec74abb395a8ab0677d4c6461c0f149b419e3
--- /dev/null
+++ b/decision/taxonomy/dka_hhs/triggers.yaml
@@ -0,0 +1,181 @@
+domain: dka_hhs
+priority: 86
+
+lexical_signals:
+  high:
+    phrases:
+      - "blood sugar over 500"
+      - "DKA"
+      - "diabetic ketoacidosis"
+      - "vomiting and blood sugar very high"
+      - "confused and sugar is sky high"
+      - "hyperglycemic crisis"
+      - "blood sugar extremely high"
+      - "sugar over 400"
+      - "sugar said HI"
+      - "meter said HI"
+      - "continuous monitor is reading HIGH"
+    regex:
+      - "(DKA|diabetic\\s+ketoacidosis)"
+      - "blood\\s+sugar\\s+(over|above|was|showed|at|read)\\s+[3-9]\\d{2}"
+      - "sugar.{0,40}(sky high|extremely high|over [3-9]\\d{2}|very high|said.{0,3}\\bHI\\b|reading.{0,3}\\bHI\\b|reading.{0,3}\\bHIGH\\b|was\\s+[3-9]\\d{2}|showed\\s+[3-9]\\d{2})"
+      - "(thirst|drink).{0,30}(pee|urinat|bathroom).{0,30}(nause|vomit|sick|confus|foggy)"
+      - "diabetes.{0,80}(confus|foggy|spaced|not\\s+(all there|making sense|thinking)|acting\\s+(weird|off|strange)|blanking|in and out|dozing|talking slow)"
+      - "(confus|foggy|spaced|acting\\s+(weird|off)|not all there|in and out).{0,80}(diabete|sugar|type [12]|insulin)"
+      - "(monitor|meter|glucometer|machine|finger\\s*(poke|prick|stick)|CGM|sensor).{0,30}(\\bHIGH\\b|\\bHI\\b|off the chart|[3-9]\\d{2})"
+      - "(\\bHIGH\\b|\\bHI\\b|[3-9]\\d{2}).{0,30}(monitor|meter|glucometer|machine|finger\\s*(poke|prick|stick)|CGM|sensor)"
+      - "said\\s*[\"']?\\bHI\\b[\"']?"
+      - "(reading|reads|read)\\s*[\"']?(\\bHI\\b|\\bHIGH\\b)[\"']?"
+      - "(sugar|glucose|blood sugar|fingerstick).{0,30}(was|showed|at|read|reads)\\s+[3-9]\\d{2}"
+      - "\\b[3-9]\\d{2}\\s*(mg/dl|mg\\/dl)\\b"
+  medium:
+    phrases:
+      - "sugar over 400 and vomiting"
+      - "diabetic emergency"
+      - "fruity breath and high sugar"
+      - "severe hyperglycemia with vomiting"
+      - "super thirsty and peeing a lot"
+      - "really thirsty and going to the bathroom constantly"
+      - "mouth feels like sandpaper"
+      - "insanely thirsty"
+      - "peeing all the time and thirsty"
+      - "blood sugar won't come down"
+      - "has diabetes and acting weird"
+      - "has diabetes and confused"
+      - "diabetic and throwing up"
+      - "sugar is high and vomiting"
+      - "mouth feels like cotton"
+      - "mouth is like sand"
+      - "it said HI"
+      - "it just said HI"
+      - "said HI on the meter"
+      - "said HI on the machine"
+      - "CGM reading HIGH"
+      - "breath smells sweet"
+      - "breath smells fruity"
+      - "breathing feels heavy"
+      - "not all there and has diabetes"
+    regex:
+      - "(thirst|thirsty|so thirsty|super thirsty).{0,60}(pee|urinat|bathroom|peeing)"
+      - "(pee|urinat|bathroom|peeing).{0,60}(thirst|thirsty)"
+      - "(nause|vomit|threw up|sick).{0,40}(thirst|thirsty|sugar|diabete)"
+      - "(sugar|glucose).{0,40}(high|spike|won'?t come down).{0,40}(vomit|nause|confus|foggy|ketone|fruity|sick|acting weird)"
+      - "(thirsty|thirst).{0,30}(dry mouth|sandpaper|cotton|sand)"
+      - "(diabete|sugar|type [12]|insulin|takes shots).{0,80}(vomit|threw up|throwing up|nause|confus|foggy|spaced|drifting|acting weird|not all there|in and out)"
+      - "(vomit|threw up|throwing up|confus|foggy|spaced|drifting|not all there|in and out).{0,80}(diabete|sugar|type [12]|insulin|takes shots)"
+      - "(breath|breathing).{0,15}(fast|deep|rapid|weird|heavy|hard|labored).{0,40}(diabete|sugar)"
+      - "(breath|mouth).{0,15}(sweet|fruity|nail polish|acetone)"
+      - "(can't keep.{0,10}down|comes back up).{0,50}(diabete|sugar|insulin|type [12])"
+  low:
+    partials:
+      - "ketoacidosis"
+      - "DKA"
+      - "HHS"
+      - "hyperglycemic"
+      - "said HI"
+      - "said HIGH"
+      - "CGM"
+      - "fingerstick"
+
+negation_handling:
+  patterns:
+    - "blood sugar is controlled"
+    - "sugar is normal"
+    - "no DKA symptoms"
+    - "diabetes well controlled"
+    - "sugars have been fine"
+    - "blood sugar is fine"
+    - "sugar a little high"
+    - "sugar a bit high"
+    - "sugar is slightly high"
+    - "glucose out of range"
+    - "blood sugar is a little elevated"
+    - "sugar was high but no other symptoms"
+    - "sugar is up but I feel fine"
+    - "no vomiting"
+    - "no confusion"
+    - "no nausea"
+    - "feeling fine just sugar is up"
+    # --- routine diabetes management context ---
+    - "A1C"
+    - "hemoglobin A1C"
+    - "metformin"
+    - "managing my diabetes"
+    - "diabetes management"
+    - "my doctor told me to check"
+    - "routine glucose check"
+    - "glucose readings"
+    - "blood sugar readings"
+    - "been checking my blood sugar"
+    - "been monitoring"
+    - "adjusting my medication"
+    - "dosing question"
+    - "energy levels are normal"
+    - "feel fine physically"
+    - "readings have been"
+    - "in the 140s"
+    - "in the 150s"
+    - "in the 160s"
+    - "in the 170s"
+    - "in the 180s"
+    # --- additional routine diabetes context ---
+    - "in the 190s"
+    - "in the 200s"
+    - "blood sugar log"
+    - "checking my numbers"
+    - "my endocrinologist"
+    - "diabetes educator"
+    # --- administrative / routine context suppression ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "when can I come in"
+    - "medication refill"
+    - "need a refill"
+    - "routine check"
+    - "just a question"
+    # --- Phase 5: R1 false escalation reduction ---
+    # Routine glucose monitoring
+    - "checking my blood sugar"
+    - "glucose meter reading"
+    - "routine glucose check"
+    - "routine blood sugar check"
+    - "checking my numbers"
+    - "my readings today"
+    - "recording my blood sugar"
+    # Diabetes management context
+    - "managing my diabetes"
+    - "known diabetic"
+    - "diabetes routine"
+    - "diabetes management plan"
+    - "my diabetes is controlled"
+    - "diabetes care"
+    # Insulin / dose adjustment questions
+    - "when should I adjust my insulin"
+    - "dose adjustment question"
+    - "insulin dosing"
+    - "sliding scale question"
+    - "basal rate question"
+    - "bolus question"
+    # Follow-up / administrative context
+    - "A1C follow-up"
+    - "hemoglobin A1C results"
+    - "taking my insulin as prescribed"
+    - "following my diabetes plan"
+    - "endocrinology appointment"
+    - "diabetes check-up"
+    - "appointment timing"
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_has_condition: ["E11.*", "E10.*", "E13.*"]
+        patient_on_medication_class: ["insulin"]
+      reason: "Diabetic on insulin with blood sugar concern"
+    - when:
+        patient_has_condition: ["E11.*", "E10.*"]
+        recent_lab:
+          code: "4548-4"
+          value_above: 9.0
+          within_days: 90
+      reason: "Diabetic with HbA1c above 9 -- elevated DKA risk"
diff --git a/decision/taxonomy/domestic_safety_concern/flows/clarify.yaml b/decision/taxonomy/domestic_safety_concern/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..bef9a5e66c7105ee65888810e1b6a7281b05aabc
--- /dev/null
+++ b/decision/taxonomy/domestic_safety_concern/flows/clarify.yaml
@@ -0,0 +1,27 @@
+flow_id: clarify
+type: clarification
+domain: domestic_safety_concern
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: domestic_safety_clarify
+      goal: "Gently ask the patient to share more about their safety situation"
+      tone: calm_concerned
+      must_include:
+        - "share"
+      must_ask:
+        - "describe"
+      must_not:
+        - "abuse"
+        - "domestic violence"
+        - "fault"
+        - "deserve"
+      max_questions: 1
+    collects:
+      - safety_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/domestic_safety_concern/flows/escalate_r2.yaml b/decision/taxonomy/domestic_safety_concern/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..894103f656caaca80382b4da0cf05827702b4557
--- /dev/null
+++ b/decision/taxonomy/domestic_safety_concern/flows/escalate_r2.yaml
@@ -0,0 +1,40 @@
+flow_id: escalate_r2
+type: escalation
+domain: domestic_safety_concern
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: domestic_safety_escalate
+      goal: "Inform the patient that a social worker will follow up. Validate their courage in sharing. Do not minimize or judge."
+      tone: calm_reassuring
+      must_include:
+        - "social worker"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "fault"
+        - "deserve"
+        - "why don't you leave"
+        - "police"
+        - "domestic violence"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: social_worker
+    urgency: same_day
+    response_spec:
+      id: domestic_safety_handoff
+      goal: "Schedule same-day social worker callback with safety concern context"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/domestic_safety_concern/flows/safety_screen.yaml b/decision/taxonomy/domestic_safety_concern/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..18c7a12e5e5419507e7c9559309d03ba8ad96a72
--- /dev/null
+++ b/decision/taxonomy/domestic_safety_concern/flows/safety_screen.yaml
@@ -0,0 +1,57 @@
+flow_id: safety_screen
+type: screening
+domain: domestic_safety_concern
+
+required_slots:
+  - harm_type
+  - immediate_danger
+  - safe_to_talk
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: domestic_safety_screen_step1
+      goal: "First assess whether the patient is safe to talk right now and whether they are in immediate danger"
+      tone: calm_concerned
+      must_include:
+        - "safe"
+      must_ask:
+        - "Are you in a safe place to talk right now?"
+        - "Are you in immediate danger?"
+      must_not:
+        - "police"
+        - "domestic violence"
+        - "abuse"
+        - "fault"
+        - "deserve"
+      max_questions: 2
+    collects:
+      - safe_to_talk
+      - immediate_danger
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: domestic_safety_screen_step2
+      goal: "Understand the nature of the safety concern without pushing for details"
+      tone: calm_concerned
+      must_include:
+        - "help"
+      must_ask:
+        - "Can you tell me a little about what is happening?"
+      must_not:
+        - "fault"
+        - "deserve"
+        - "why don't you leave"
+        - "police"
+      max_questions: 1
+    collects:
+      - harm_type
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_r3: escalate_r2
+  on_low_risk: escalate_r2
+  on_unclear: escalate_r2
diff --git a/decision/taxonomy/domestic_safety_concern/flows/warm_transfer_social_work.yaml b/decision/taxonomy/domestic_safety_concern/flows/warm_transfer_social_work.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..79ecf78a286453208bf5eb5d1199100f04ffb2fc
--- /dev/null
+++ b/decision/taxonomy/domestic_safety_concern/flows/warm_transfer_social_work.yaml
@@ -0,0 +1,23 @@
+flow_id: warm_transfer_social_work
+type: resolution
+domain: domestic_safety_concern
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: domestic_safety_social_work_referral
+      goal: "Inform the patient their care team includes people who can help with safety concerns and connect them with resources"
+      tone: warm_empathetic
+      must_include:
+        - "care team"
+        - "resources"
+        - "help"
+      must_not:
+        - "fault"
+        - "deserve"
+        - "victim"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/domestic_safety_concern/rules.yaml b/decision/taxonomy/domestic_safety_concern/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..58e9dd1e01dbe3d77de6c28352d2d20961c8b03f
--- /dev/null
+++ b/decision/taxonomy/domestic_safety_concern/rules.yaml
@@ -0,0 +1,33 @@
+domain: domestic_safety_concern
+target_risk_class: R2
+
+decision_rules:
+  - id: domestic_safety_concern_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: domestic_safety_concern_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: domestic_safety_concern_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: domestic_safety_concern_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r2
+
+  - id: domestic_safety_concern_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/domestic_safety_concern/triggers.yaml b/decision/taxonomy/domestic_safety_concern/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..24d5414e3a84b993b27e16d12f2942f539d6c747
--- /dev/null
+++ b/decision/taxonomy/domestic_safety_concern/triggers.yaml
@@ -0,0 +1,88 @@
+domain: domestic_safety_concern
+priority: 72
+
+lexical_signals:
+  high:
+    phrases:
+      - "not safe at home"
+      - "he hits me"
+      - "she hits me"
+      - "afraid of my partner"
+      - "being hurt at home"
+      - "locked in the house"
+      - "can't leave the house"
+      - "threatens me"
+      - "scared of my husband"
+      - "scared of my wife"
+      - "he won't let me leave"
+      - "she won't let me leave"
+      - "being abused"
+      - "elder abuse"
+      - "someone is hurting me"
+      - "hit me last night"
+      - "chokes me"
+      - "afraid to go home"
+      - "my partner hurts me"
+      - "beaten by my spouse"
+      - "they take my money"
+      - "won't let me see the doctor"
+      - "controls everything I do"
+      - "threatened to kill me"
+      - "afraid for my life at home"
+      - "bruises from being hit"
+    regex:
+      - "(not|don't\\s+feel|never)\\s+safe.{0,15}(at\\s+home|here|in\\s+my\\s+house|with\\s+him|with\\s+her)"
+      - "(he|she|my\\s+partner|my\\s+husband|my\\s+wife|my\\s+spouse|they).{0,15}(hit|hits|beat|beats|hurt|hurts|choke|chokes|threaten|threatens|abuse|abuses)\\s+me"
+      - "(afraid|scared|terrified|frightened).{0,15}(of|to\\s+go\\s+home|my\\s+partner|my\\s+husband|my\\s+wife|my\\s+spouse)"
+      - "(can't|cannot|won't\\s+let\\s+me)\\s+(leave|go\\s+out|see\\s+the\\s+doctor|call|get\\s+help)"
+      - "(locked|trapped|stuck).{0,10}(in|at).{0,10}(house|home|room)"
+      - "(elder|being).{0,10}(abuse|abused|neglected|mistreated)"
+      - "(take|takes|took|control).{0,15}(my\\s+money|my\\s+medication|everything)"
+  medium:
+    phrases:
+      - "don't feel safe"
+      - "afraid at home"
+      - "partner is aggressive"
+      - "yells at me all the time"
+      - "pushed me"
+      - "grabbed me"
+      - "afraid of someone at home"
+      - "home situation is bad"
+      - "being mistreated"
+      - "someone takes advantage of me"
+      - "no control over my life"
+      - "not allowed to go out"
+      - "treated badly at home"
+    regex:
+      - "(don't|do\\s+not)\\s+feel\\s+safe"
+      - "(afraid|scared).{0,10}(at\\s+home|of\\s+someone)"
+      - "(push|grab|shove|yell|scream).{0,10}(at|ed)\\s+me"
+      - "(mistreat|neglect|take\\s+advantage).{0,10}(me|of\\s+me)"
+  low:
+    partials:
+      - "not safe"
+      - "afraid at home"
+      - "abuse"
+      - "hurt by someone"
+      - "domestic"
+
+negation_handling:
+  patterns:
+    - "i feel safe at home"
+    - "i am safe at home"
+    - "i'm safe at home"
+    - "no safety concerns"
+    - "home is fine"
+    - "everything is okay at home"
+    - "safe environment"
+    - "good relationship"
+    - "partner is supportive"
+    - "not afraid"
+    - "i feel safe"
+    - "comfortable at home"
+    - "no one is hurting me"
+    - "not being abused"
+    - "no abuse"
+    - "home situation is good"
+    - "happy at home"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/dvt_signal/flows/clarify.yaml b/decision/taxonomy/dvt_signal/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..68199881645075db140ca8a87696b40d09ae3334
--- /dev/null
+++ b/decision/taxonomy/dvt_signal/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: dvt_signal
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: dvt_signal_clarify
+      goal: "Ask patient to describe their dvt signal symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - dvt_signal_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/dvt_signal/flows/escalate_r2.yaml b/decision/taxonomy/dvt_signal/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c352f85b380cbea46ffbaeda886c1c619de2b4ab
--- /dev/null
+++ b/decision/taxonomy/dvt_signal/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: dvt_signal
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/dvt_signal/flows/handoff.yaml b/decision/taxonomy/dvt_signal/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..34d35285a9723b14236f3fe5c9fda953410e241f
--- /dev/null
+++ b/decision/taxonomy/dvt_signal/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: dvt_signal
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: dvt_signal_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: dvt_signal_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/dvt_signal/flows/reassure_low_risk.yaml b/decision/taxonomy/dvt_signal/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6f169fcc5a9b2d8b3f9a76dd8147e790e12030da
--- /dev/null
+++ b/decision/taxonomy/dvt_signal/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: dvt_signal
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: dvt_signal_reassure
+      goal: "Acknowledge the patient's concern about leg symptoms, note that their care team will be informed for routine follow-up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/dvt_signal/flows/safety_screen.yaml b/decision/taxonomy/dvt_signal/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..61815e0e6eddfb7039c25650b0c5df92e2118eaf
--- /dev/null
+++ b/decision/taxonomy/dvt_signal/flows/safety_screen.yaml
@@ -0,0 +1,54 @@
+flow_id: safety_screen
+type: screening
+domain: dvt_signal
+
+required_slots:
+  - leg_swelling_acute
+  - calf_tenderness
+  - immobility_history
+  - leg_warmth_redness
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: dvt_signal_screen_step1
+      goal: "Determine whether leg swelling is acute and unilateral"
+      tone: calm_urgent
+      must_include:
+        - "leg"
+      must_ask:
+        - "Is the swelling in one leg only, and did it come on recently?"
+        - "Is your calf tender or painful when you touch it or walk?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - leg_swelling_acute
+      - calf_tenderness
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: dvt_signal_screen_step2
+      goal: "Screen for DVT risk factors and additional signs"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "Have you been sitting or lying still for long periods recently — like a long trip or bed rest?"
+        - "Is the affected leg warm to the touch or red?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - immobility_history
+      - leg_warmth_redness
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_r2
diff --git a/decision/taxonomy/dvt_signal/rules.yaml b/decision/taxonomy/dvt_signal/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f219c87e7f3ff1a813be7c29791ad818b3688863
--- /dev/null
+++ b/decision/taxonomy/dvt_signal/rules.yaml
@@ -0,0 +1,27 @@
+domain: dvt_signal
+target_risk_class: R2
+
+decision_rules:
+  - id: dvt_signal_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: dvt_signal_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: dvt_signal_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: dvt_signal_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/dvt_signal/triggers.yaml b/decision/taxonomy/dvt_signal/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d6b9e2b823dabf715b13497d57b8027f6265fe3b
--- /dev/null
+++ b/decision/taxonomy/dvt_signal/triggers.yaml
@@ -0,0 +1,291 @@
+domain: dvt_signal
+priority: 77
+
+lexical_signals:
+  high:
+    phrases:
+      - "leg is swollen and painful"
+      - "DVT"
+      - "deep vein thrombosis"
+      - "calf is red and swollen"
+      - "unilateral leg swelling"
+      - "left calf is swollen and tight"
+      - "calf looks puffy and feels weird"
+      - "one of my legs feels bigger"
+      - "one leg is swollen and the other is normal"
+      - "my left leg is twice the size of my right"
+      - "calf is hard and swollen on one side"
+      - "leg swelled up after my surgery"
+      - "one leg is red hot and swollen"
+      - "blood clot in my leg"
+      - "doctor said it might be a clot"
+      - "calf is painful and swollen since my flight"
+      - "one ankle is hugely swollen"
+      - "leg suddenly swelled up overnight"
+      - "whole leg from thigh to ankle is swollen"
+      - "positive Homans sign"
+      - "calf pain with dorsiflexion"
+      - "my leg blew up after being on bed rest"
+      - "leg has been swollen and warm for two days"
+    regex:
+      - "(DVT|deep\\s+vein\\s+thrombosis)"
+      - "(one|unilateral|left|right)\\s+(leg|calf)\\s+(swell|is\\s+swoll|looks?\\s+puff)"
+      - "(calf|leg).*(swollen|puffy|tight|thicker).*(one|asymmetric|other)"
+      - "one\\s+leg\\s+much\\s+bigger\\s+than\\s+the\\s+other"
+      - "pant\\s+leg\\s+(is\\s+)?tight"
+      - "blood\\s+clot.*(leg|calf)"
+      - "(leg|calf).*(blood\\s+clot)"
+      - "(leg|calf).*(twice|double|way\\s+bigger).*than.*(other|right|left)"
+      - "(leg|calf).*(suddenly|overnight|woke\\s+up).*(swell|swoll|puff|big)"
+      - "(suddenly|overnight|woke\\s+up).*(leg|calf).*(swell|swoll|puff|big)"
+      - "(surgery|procedure|bed\\s+rest|immobil|cast).*(leg|calf).*(swell|swoll)"
+      - "(leg|calf).*(swell|swoll).*(surgery|procedure|bed\\s+rest|flight|travel)"
+      - "Homans"
+      - "(whole|entire)\\s+(leg|calf).*(swell|swoll|puff|big)"
+      - "(leg|calf).*(hard|firm|taut).*(swell|swoll)"
+  medium:
+    phrases:
+      - "leg swelling getting worse"
+      - "calf pain and swelling"
+      - "one leg is swollen"
+      - "leg pain and warmth"
+      - "swollen leg since surgery"
+      - "asymmetric leg swelling"
+      - "calf looks noticeably thicker"
+      - "ankle looks a little puffy"
+      - "left calf looks puffy"
+      - "leg feels kind of off"
+      - "comparing them in the mirror"
+      - "definitely asymmetric"
+      - "clot risks after long flights"
+      - "his calf hurts bad"
+      - "my sock is leaving a deeper mark on one leg"
+      - "shoe feels tighter on one foot"
+      - "leg aches and feels heavy"
+      - "calf is sore and warm to the touch"
+      - "my leg has been swollen for a few days"
+      - "pitting edema in one leg"
+      - "one ankle is puffier than the other"
+      - "leg feels heavy and tight"
+      - "been sitting a lot and now my leg hurts"
+      - "calf cramp that won't go away"
+      - "leg pain worse when I walk"
+      - "swelling that started after the long drive"
+      - "my calf has a deep ache"
+      - "leg is discolored and swollen"
+      - "pain behind my knee and calf is swollen"
+      - "thigh feels tight and swollen"
+      - "leg swelling not going down with elevation"
+      # --- Phase 6: R2 recall expansion ---
+      - "leg is swollen and red"
+      - "calf is tender and warm"
+      - "one leg bigger than the other"
+      - "leg pain after sitting"
+      - "swelling won't go down"
+      # --- Phase 7: Classic DVT triad ---
+      - "leg swelling"
+      - "swelling in my leg"
+      - "swelling in my left leg"
+      - "swelling in my right leg"
+      - "calf pain"
+      - "calf is painful"
+      - "calf is sore"
+      - "calf is tender"
+      - "warmth in leg"
+      - "warmth in my leg"
+      - "leg feels warm"
+      - "leg is warm"
+      - "calf feels warm"
+      - "calf is warm"
+      - "leg looks puffy"
+      - "lower leg looks puffy"
+      - "calf looks puffy"
+      - "ankle looks puffy"
+      # --- Phase 7: Risk factor context ---
+      - "after surgery and leg swelling"
+      - "long flight and leg pain"
+      - "long flight and leg swelling"
+      - "after the flight my leg"
+      - "since the flight my leg"
+      - "drove for hours"
+      - "drove for hours and didn't stop"
+      - "drove and didn't stop much"
+      - "sat for hours"
+      - "sat for hours at a time"
+      - "sitting for a long time"
+      - "been sitting a lot"
+      - "planted in the chair"
+      - "didn't get up much"
+      - "pinned in my seat"
+      - "pinned in the window seat"
+      # --- Phase 7: Asymmetry ---
+      - "one leg bigger"
+      - "one leg is bigger"
+      - "one leg bigger than other"
+      - "one leg bigger than the other"
+      - "swelling just in one leg"
+      - "swelling in one leg only"
+      - "only the left leg"
+      - "only the right leg"
+      - "just the left leg"
+      - "just the right leg"
+      - "other leg is normal"
+      - "other leg is totally normal"
+      - "right leg is totally normal"
+      - "left leg is totally normal"
+      - "one side only"
+      - "sock tighter on one side"
+      - "sock is tighter on one side"
+      - "sock line deeper on one side"
+      - "pant leg feels snug"
+      - "pant leg feels tight"
+      # --- Phase 7: Color changes ---
+      - "leg looks red"
+      - "leg is red"
+      - "calf looks red"
+      - "calf is red"
+      - "discoloration in leg"
+      - "discoloration in calf"
+      - "slight discoloration"
+      - "leg is discolored"
+      - "calf is discolored"
+      - "leg looks flushed"
+      - "calf looks flushed"
+      - "more flushed than usual"
+      - "slightly more pink"
+      - "faint pinkish area"
+      - "mild redness"
+      - "slightly darker"
+      - "temperature difference"
+    regex:
+      - "(calf|leg).*(puffy|swollen|thick|warm|tight|bigger)"
+      - "(noticed|something).*(off|wrong|weird).*\\b(leg|calf)\\b"
+      - "\\b(leg|calf)\\b.*(off|wrong|weird|bigger|different)"
+      - "(after|since|from)\\s+(long\\s+)?(flight|sitting|travel|surgery|car)"
+      - "clot\\s+(risk|worry|scare)"
+      - "something\\s+(off|wrong|weird).*\\bleg\\b"
+      - "something\\s+with\\s+(his|her|my)\\s+leg"
+      - "(calf|leg)\\s+hurts?\\s+(bad|a\\s+lot)"
+      - "(calf|leg).*(cramp|pain).*won't\\s+quit"
+      - "leg.*(pain|limp|hurt).*([78])\\s*(out\\s+of|/)"
+      - "body\\s+feels\\s+off"
+      - "(sitting|sat)\\s+a\\s+lot"
+      - "leg\\s+thing"
+      - "sock.*(mark|indent|impression).*(one|left|right)\\s+(leg|ankle)"
+      - "shoe.*(tight|snug).*(one|left|right)\\s+(foot|ankle)"
+      - "(leg|calf).*(ache|heavy|tight|sore).*(warm|hot)"
+      - "(leg|calf).*(swell|swoll|puff).*few\\s+days"
+      - "pitting\\s+edema"
+      - "(leg|calf).*(discolor|purpl|bluish|reddish)"
+      - "behind\\s+(my\\s+)?knee.*(pain|sore|ache|swell)"
+      - "(thigh|upper\\s+leg).*(tight|swell|swoll|pain)"
+      - "(leg|calf).*(swell|swoll).*(not|won't|doesn't).*(go\\s+down|improv|better)"
+      - "(elevation|elevat|prop).*(not|doesn't|won't).*(help|work|reduc)"
+      - "(long\\s+)?(drive|road\\s+trip|car\\s+ride).*(leg|calf).*(swell|pain|ache)"
+      - "(leg|calf).*(deep\\s+ache|deep\\s+pain|dull\\s+ache)"
+      # --- Phase 6: R2 recall expansion ---
+      - "(leg|calf|thigh).{0,20}(swollen|swelling|bigger).{0,20}(red|warm|tender|painful)"
+      - "one.{0,10}(leg|calf).{0,20}(bigger|larger|more swollen).{0,15}(than|other)"
+      - "(after|from).{0,15}(sitting|flight|travel|driving).{0,20}(leg|calf).{0,15}(swell|pain|hurt)"
+      - "(swelling|pain).{0,15}(won't|doesn't|not).{0,10}(go down|improve|better)"
+      # --- Phase 7: Classic triad regex ---
+      - "(leg|calf|ankle).{0,15}(swelling|swollen|puffy|puffiness)"
+      - "(calf|leg).{0,15}(pain|painful|sore|tender|tenderness)"
+      - "(leg|calf).{0,15}(feels?|is).{0,10}(warm|warmer|hot)"
+      - "(warmth|warm).{0,15}(in|on).{0,10}(the\\s+)?(leg|calf)"
+      # --- Phase 7: Risk factor context regex ---
+      - "(after|since|from).{0,15}(the\\s+)?flight.{0,15}(my\\s+)?(leg|calf)"
+      - "(drove|driving|drive).{0,20}(hours|long\\s+time|didn'?t\\s+stop)"
+      - "(sat|sitting|been\\s+sitting).{0,15}(for\\s+)?(hours|long\\s+time|a\\s+lot)"
+      - "(planted|stuck|pinned).{0,15}(in|at).{0,15}(chair|seat|desk)"
+      - "(didn'?t|don'?t).{0,10}(get\\s+up|move).{0,10}(much|often)"
+      # --- Phase 7: Asymmetry regex ---
+      - "one.{0,10}(leg|calf).{0,10}(is\\s+)?(bigger|larger|more\\s+swollen)"
+      - "(just|only).{0,10}(the\\s+)?(left|right).{0,10}(leg|calf)"
+      - "(other|opposite).{0,10}(leg|calf).{0,10}(is\\s+)?(normal|fine|okay)"
+      - "sock.{0,15}(tighter|deeper|mark|line).{0,15}(on\\s+)?one.{0,10}(side|leg)"
+      - "pant.{0,10}leg.{0,10}(feels?|is).{0,10}(snug|tight)"
+      # --- Phase 7: Color changes regex ---
+      - "(leg|calf).{0,15}(looks?|is).{0,10}(red|reddish|pink|pinkish|flushed)"
+      - "(discoloration|discolored).{0,15}(in|on|of).{0,15}(the\\s+)?(leg|calf)"
+      - "(slight|mild|faint).{0,10}(discoloration|redness|pinkish)"
+      - "(slightly|more).{0,10}(darker|pink|flushed).{0,10}(than|area)"
+      - "temperature.{0,10}difference"
+  low:
+    partials:
+      - "leg swelling"
+      - "calf pain"
+      - "DVT"
+      - "thrombosis"
+      - "leg puffy"
+      - "calf swollen"
+      - "calf tight"
+      - "leg bigger"
+      - "blood clot"
+      - "leg feels off"
+      - "calf hurts"
+      - "leg hurts"
+      - "limping"
+      - "leg heavy"
+      - "calf ache"
+      - "ankle puffy"
+      - "leg discolored"
+      - "leg warm"
+      - "pitting edema"
+      - "leg not improving"
+      - "sock mark"
+      - "calf cramping"
+      - "behind knee pain"
+
+negation_handling:
+  patterns:
+    - "no leg swelling"
+    - "legs are fine"
+    - "swelling went down"
+    - "both legs same"
+    - "legs look normal"
+    - "no DVT"
+    - "DVT was ruled out"
+    - "ultrasound was negative"
+    - "no blood clot"
+    - "clot was ruled out"
+    - "legs are equal size"
+    - "swelling resolved"
+    - "leg is back to normal"
+    - "no calf tenderness"
+    - "both calves the same"
+    - "leg swelling improved"
+    - "no pain in the calf"
+    - "legs are symmetric"
+    - "doppler was negative"
+    - "no evidence of clot"
+    - "swelling going down with elevation"
+    - "leg looks normal now"
+    - "calf pain resolved"
+    # --- post-procedure/incontinence context (R1 scenarios) ---
+    - "bladder surgery"
+    - "prostate surgery"
+    - "prostate procedure"
+    - "TURP"
+    - "hysterectomy"
+    - "bladder control"
+    - "incontinence"
+    - "incontinence since surgery"
+    - "urine leakage since surgery"
+    - "leaking urine"
+    - "urine leakage"
+    - "pelvic floor"
+    - "wearing pads"
+    - "urological"
+    - "urology"
+    - "catheter removal"
+    - "catheter out"
+    - "after the catheter"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/ectopic_signal/flows/clarify.yaml b/decision/taxonomy/ectopic_signal/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8eb26e40f581008a33ac6dc9e23945fa5e2f1ddd
--- /dev/null
+++ b/decision/taxonomy/ectopic_signal/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: ectopic_signal
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: ectopic_signal_clarify
+      goal: "Ask patient to describe their ectopic signal symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - ectopic_signal_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/ectopic_signal/flows/escalate_r2.yaml b/decision/taxonomy/ectopic_signal/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ce5169b92528ba5519f2b04493b23f1c6e3c49e6
--- /dev/null
+++ b/decision/taxonomy/ectopic_signal/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: ectopic_signal
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/ectopic_signal/flows/handoff.yaml b/decision/taxonomy/ectopic_signal/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d9ce65789816ddb610791bbd58555714a4d02f52
--- /dev/null
+++ b/decision/taxonomy/ectopic_signal/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: ectopic_signal
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: ectopic_signal_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: ectopic_signal_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/ectopic_signal/flows/safety_screen.yaml b/decision/taxonomy/ectopic_signal/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3db78886126e83a37ec29ef8a24c4de95ff7fee8
--- /dev/null
+++ b/decision/taxonomy/ectopic_signal/flows/safety_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: safety_screen
+type: screening
+domain: ectopic_signal
+
+required_slots:
+  - pain_location
+  - bleeding_status
+  - pregnancy_status
+  - pain_severity
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "pain location"
+        - "bleeding status"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - pain_location
+      - bleeding_status
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "pregnancy status"
+        - "pain severity"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - pregnancy_status
+      - pain_severity
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/decision/taxonomy/ectopic_signal/rules.yaml b/decision/taxonomy/ectopic_signal/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..2266904a4e31f8a014c1d14c22ed35081d6cdcbd
--- /dev/null
+++ b/decision/taxonomy/ectopic_signal/rules.yaml
@@ -0,0 +1,27 @@
+domain: ectopic_signal
+target_risk_class: R2
+
+decision_rules:
+  - id: ectopic_signal_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: ectopic_signal_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: ectopic_signal_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: ectopic_signal_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/ectopic_signal/triggers.yaml b/decision/taxonomy/ectopic_signal/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3ad5dafef62f1bd11c43a8caebc62650de167c1f
--- /dev/null
+++ b/decision/taxonomy/ectopic_signal/triggers.yaml
@@ -0,0 +1,160 @@
+domain: ectopic_signal
+priority: 71
+
+lexical_signals:
+  high:
+    phrases:
+      - 'pregnant with severe abdominal pain'
+      - 'sharp pain on one side and pregnant'
+      - 'possible ectopic pregnancy'
+      - 'pregnant and sharp pelvic pain'
+      - 'lower abdominal pain and could be pregnant'
+      - 'sharp pain low on the right side of my pelvis'
+      - 'one-sided pain and spotting'
+      - 'pregnant and spotting with pain'
+      - 'positive home test and pain'
+      - 'pregnant and bleeding with sharp pain'
+      - 'shoulder tip pain and pregnant'
+      - 'stabbing pain in my pelvis and positive pregnancy test'
+      - 'six weeks pregnant with one-sided pain'
+      - 'just found out I am pregnant and have terrible pain on one side'
+      - 'sharp pain right above my hip and I missed my period'
+      - 'excruciating one-sided pain and vaginal bleeding'
+      - 'collapsed from pain and I am early pregnant'
+      - 'pregnant and pain is shooting to my shoulder'
+      - 'positive test this morning and now sharp lower pain'
+      - 'IVF pregnancy with sudden pelvic pain'
+    regex:
+      - 'pregnant.*(abdominal|pelvic|belly|stomach)\s+pain'
+      - 'ectopic\s+pregnancy'
+      - '(sharp|stabbing)\s+pain.*(one[- ]?sided|right side|left side).*(pelv|abdomen|belly)'
+      - '(spotting|bleeding).*(pregnant|positive\s+test)'
+      - 'pregnant.*(spotting|bleeding).*(pain|cramp)'
+      - '\d+\s+weeks?\s+pregnant.*(pain|bleed|spot)'
+      - '(positive\s+(home\s+)?test|missed\s+(my\s+)?period).{0,30}(sharp|stab|severe).{0,15}pain'
+      - '(sharp|stab|severe).{0,15}pain.{0,30}(positive\s+test|missed\s+(my\s+)?period|pregnant)'
+      - 'shoulder\s+(tip\s+)?pain.{0,25}(pregnant|positive\s+test|early\s+pregnancy|bleeding)'
+      - '(pregnant|early\s+pregnancy).{0,25}shoulder\s+(tip\s+)?pain'
+      - '(collapsed|fainted|passed\s+out).{0,25}(pregnant|early\s+pregnancy|positive\s+test)'
+      - '(IVF|fertility\s+treatment).{0,25}(pain|bleed|cramp)'
+      - '(pregnant|positive\s+test).{0,30}(dizzy|faint|lightheaded|pale|cold|clammy)'
+  medium:
+    phrases:
+      - 'pregnant with cramping'
+      - 'one-sided pelvic pain and pregnant'
+      - 'pregnant and lower belly pain'
+      - 'abdominal pain in early pregnancy'
+      - 'pain and might be pregnant'
+      - 'pregnant with spotting and pain'
+      - 'light bleeding when I wipe'
+      - 'sharp cramps that come and go'
+      - 'feeling woozy and cramping'
+      - 'cramps are sharp'
+      - 'pain spikes and then calms down'
+      - 'got really pale'
+      - 'felt floaty'
+      - 'bleeding like spotting'
+      - 'pink to brown spotting'
+      - 'my period is late and I have pain on one side'
+      - 'brownish discharge and pain low down'
+      - 'pain worse on one side than the other'
+      - 'feels like something is pulling inside my pelvis'
+      - 'cramping only on my right side'
+      - 'cramping only on my left side'
+      - 'sharp pinch feeling down low'
+      - 'bleeding is dark red almost brown'
+      - 'I feel faint and my stomach is killing me'
+      - 'something feels wrong with this pregnancy'
+      - 'pain goes into my bum when I sit'
+      - 'rectal pressure and pelvic pain'
+      - 'watery bleeding with clots'
+      - 'had a miscarriage before and having one-sided pain'
+      - 'IUD removed and now pain with spotting'
+      - 'pain that takes my breath away low in my belly'
+      - 'dizzy when I stand and I have been spotting'
+      - 'my right side feels like it is being stabbed'
+      - 'my left side feels like it is being stabbed'
+      # --- MINIMIZER coverage ---
+      - "there might have been some spotting"
+      - "not exactly sharp, more like a crampy pressure"
+      - "it kind of moves around, maybe just indigestion"
+      - "a little bit of spotting I guess"
+      - "tenderness but not sure if that counts as pain"
+      - "probably just normal pregnancy stuff"
+      - "cramps aren't that bad, just kind of there"
+      - "just some light bleeding, probably nothing"
+      - "a bit of discomfort on one side"
+      - "spotting is probably just normal"
+    regex:
+      - '(cramp|pain).*(one[- ]?sided|right\s+side|left\s+side)'
+      - '(light|mild)\s+(bleed|spot).*wipe'
+      - '(woozy|dizzy|lightheaded).*(cramp|pain|bleed)'
+      - 'spotting.*(not\s+)?(heavy|soaking|filling)'
+      - '(sharp|stabbing).*(cramp|pain|pinch).*(come|wave)'
+      - 'soaking\s+through\s+pads'
+      - 'sharp-?ish\s+(cramp|pain)'
+      - '(sweaty|shaky|pale).*(stomach|belly|abdomen|cramp)'
+      - '(stomach|belly).*(weird|off|funny|uncomfortable)'
+      - 'felt.*(floaty|faint|woozy|dizzy)'
+      - '(period|menstrual).{0,15}(late|missed|overdue).{0,25}pain'
+      - '(brown|dark\s+red|watery).{0,15}(discharge|bleed|blood|spotting)'
+      - '(pull|tug|twist).{0,15}(inside|pelv|lower|low\s+down)'
+      - '(rectal|bum|bottom)\s+(pressure|pain).{0,20}(pelv|cramp|bleed)'
+      - '(miscarriage|ectopic)\s+(before|history|previous).{0,20}(pain|bleed|spot)'
+      - '(breath\s+away|double\s+over|doubled\s+over).{0,20}(belly|pelv|lower|pain)'
+      - '(IUD|coil).{0,15}(remov|taken\s+out).{0,20}(pain|bleed|spot)'
+      - '(faint|dizzy|lightheaded).{0,20}(stand|stood|get\s+up).{0,20}(spot|bleed)'
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(just|only).{0,10}(a\\s+)?(little|bit|slight|some).{0,10}(spotting|bleeding|cramp|discomfort|tender).{0,20}(pregnant|pregnancy|positive test|missed period)"
+      - "(pregnant|pregnancy|positive test).{0,25}(just|only).{0,10}(a\\s+)?(little|bit|slight|some).{0,10}(spotting|bleeding|cramp|discomfort|tender)"
+      - "(probably|might be).{0,10}(just|nothing|normal|fine).{0,20}(spotting|bleeding|cramp|pregnancy)"
+      - "(cramp|pain|discomfort|tender).{0,15}(kind of|sort of|not really|not exactly|not sure).{0,15}(sharp|bad|serious|count)"
+      - "(spotting|bleeding).{0,15}(probably|might be|could be).{0,10}(just|nothing|normal|fine|implantation)"
+      # --- additional early pregnancy risk ---
+      - "(pregnant|positive\\s+test).{0,25}(sharp|stab|severe|sudden)\\s+(pain|cramp)"
+      - "(bleeding|spotting).{0,20}(heavier|getting worse|increasing|more)"
+  low:
+    partials:
+      - 'ectopic'
+      - 'pregnant pain'
+      - 'pelvic pain pregnant'
+      - 'spotting'
+      - 'cramping'
+      - 'one-sided pain'
+      - 'bleeding when I wipe'
+      - 'woozy'
+      - 'pinch feeling'
+      - 'shoulder tip pain'
+      - 'late period pain'
+      - 'brown discharge'
+      - 'early pregnancy pain'
+      - 'pelvic pressure'
+      - 'tubal pregnancy'
+      - 'pain low down'
+      - 'implantation pain'
+      - 'positive test pain'
+
+negation_handling:
+  patterns:
+    - 'no abdominal pain during pregnancy'
+    - 'not pregnant'
+    - 'cramping resolved'
+    - 'not soaking pads'
+    - 'bleeding stopped'
+    - 'pain has gone away'
+    - 'no longer spotting'
+    - 'spotting stopped on its own'
+    - 'ectopic was ruled out'
+    - 'scan showed normal pregnancy'
+    - 'confirmed intrauterine pregnancy'
+    - 'no pelvic pain'
+    - 'not having any bleeding'
+    - 'pregnancy test was negative'
+    - 'pain completely resolved'
+    - 'ultrasound was normal'
+    - 'definitely not pregnant'
+    - 'tubes were tied'
+    - 'had a hysterectomy'
+    - 'bleeding was just my period'
+    - 'cramps went away after paracetamol'
+  action: downgrade_confidence
diff --git a/decision/taxonomy/exertional_dyspnea/flows/clarify.yaml b/decision/taxonomy/exertional_dyspnea/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..cb1b73233fe4ebcdd6b5a6edc319cd9cde1ebc6d
--- /dev/null
+++ b/decision/taxonomy/exertional_dyspnea/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: exertional_dyspnea
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: exertional_dyspnea_clarify
+      goal: "Ask patient to describe their exertional dyspnea symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - exertional_dyspnea_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/exertional_dyspnea/flows/escalate_r1.yaml b/decision/taxonomy/exertional_dyspnea/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a69676e661caa46e89a8f875efce8fa15d4e44a7
--- /dev/null
+++ b/decision/taxonomy/exertional_dyspnea/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: exertional_dyspnea
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/exertional_dyspnea/flows/escalate_r3.yaml b/decision/taxonomy/exertional_dyspnea/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e15da8000af4762125c0d840291deefcfd9d1b83
--- /dev/null
+++ b/decision/taxonomy/exertional_dyspnea/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: exertional_dyspnea
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Instruct patient to call 911 immediately and inform them of nurse transfer"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/exertional_dyspnea/flows/handoff.yaml b/decision/taxonomy/exertional_dyspnea/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1c5b39bb153895858502ff910dc6c5857f1c24bb
--- /dev/null
+++ b/decision/taxonomy/exertional_dyspnea/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: exertional_dyspnea
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: exertional_dyspnea_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: exertional_dyspnea_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/exertional_dyspnea/flows/safety_screen.yaml b/decision/taxonomy/exertional_dyspnea/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6ef0db43482604a2b69f65c1e798851b3131c7a5
--- /dev/null
+++ b/decision/taxonomy/exertional_dyspnea/flows/safety_screen.yaml
@@ -0,0 +1,33 @@
+flow_id: safety_screen
+type: screening
+domain: exertional_dyspnea
+
+required_slots:
+  - dyspnea_onset
+  - dyspnea_duration
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: exertional_dyspnea_screen_step1
+      goal: "Determine whether dyspnea is new onset or chronic worsening"
+      tone: calm_urgent
+      must_include:
+        - "shortness of breath"
+      must_ask:
+        - "When did you first notice the shortness of breath with activity?"
+        - "Is this something new, or has it been going on for a while?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - dyspnea_onset
+      - dyspnea_duration
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_low_risk: escalate_r1
+  on_unclear: escalate_r3
diff --git a/decision/taxonomy/exertional_dyspnea/rules.yaml b/decision/taxonomy/exertional_dyspnea/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e4771c0b120f7d9b155dbeaa789bbc862f13bb6f
--- /dev/null
+++ b/decision/taxonomy/exertional_dyspnea/rules.yaml
@@ -0,0 +1,33 @@
+domain: exertional_dyspnea
+target_risk_class: R3
+
+decision_rules:
+  - id: exertional_dyspnea_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: exertional_dyspnea_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: exertional_dyspnea_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: exertional_dyspnea_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: exertional_dyspnea_r1_escalation
+    if:
+      risk_class: R1
+    then:
+      flow: escalate_r1
diff --git a/decision/taxonomy/exertional_dyspnea/triggers.yaml b/decision/taxonomy/exertional_dyspnea/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..71fd7a0f8383d59e61aa895a0d3e7584b5392a5d
--- /dev/null
+++ b/decision/taxonomy/exertional_dyspnea/triggers.yaml
@@ -0,0 +1,117 @@
+domain: exertional_dyspnea
+priority: 39
+
+lexical_signals:
+  high:
+    phrases:
+      - "short of breath when I walk"
+      - "can't breathe on exertion"
+      - "winded going up stairs"
+      - "breathless with any activity"
+      - "shortness of breath with exercise"
+      - "out of breath just walking to bathroom"
+      - "can't walk without getting winded"
+      - "short of breath doing simple things"
+      - "huffing and puffing going up stairs"
+      - "out of breath walking across the room"
+      - "can barely walk without stopping to breathe"
+      - "get winded doing anything physical"
+      - "short of breath when I move around"
+    regex:
+      - "short(ness)?\\s+of\\s+breath.*(walk|exert|stair|activ|mov|simple|doing)"
+      - "(winded|breathless).*(walk|exert|stair|activ|mov|doing)"
+      - "(out\\s+of|short\\s+of)\\s+breath.*(walk|stair|room|bath|mov)"
+      - "(can'?t|can\\s+barely)\\s+(walk|move|breathe).*(without|exert|stair)"
+      - "(huffing|puffing|gasping).*(stair|walk|exert)"
+  medium:
+    phrases:
+      - "more short of breath with activity"
+      - "getting winded more easily"
+      - "breathless when walking"
+      - "exertion makes me breathless"
+      - "out of breath with movement"
+      - "need to rest after walking"
+      - "having trouble catching my breath"
+      - "winded easily"
+      - "breathing harder with activity"
+      - "get tired quickly when moving"
+      - "can't do as much as before"
+      # --- additional naturalistic ---
+      - "I have to stop and catch my breath"
+      - "can't even walk to the mailbox"
+      - "used to be able to do this without getting winded"
+  low:
+    partials:
+      - "exertional dyspnea"
+      - "winded"
+      - "breathless activity"
+      - "out of breath"
+      - "short of breath walking"
+
+negation_handling:
+  patterns:
+    - "no shortness of breath with activity"
+    - "breathing fine with exercise"
+    - "not winded"
+    - "no shortness of breath"
+    - "not short of breath"
+    - "breathing fine"
+    - "breathing is fine"
+    - "breathing normally"
+    - "can breathe okay"
+    - "no trouble breathing"
+    - "no difficulty breathing"
+    # --- baseline / recovery context ---
+    - "that's normal for me"
+    - "always been like that"
+    - "always get winded"
+    - "been that way since"
+    - "getting better"
+    - "getting better though"
+    - "improving"
+    - "used to be worse"
+    - "better than before"
+    - "better than it was"
+    - "normal for my age"
+    - "doctor said that's expected"
+    - "I just need to take it easy"
+    - "I just need to pace myself"
+    - "I know I need to take it slow"
+    - "but I'm okay once I sit down"
+    - "but it goes away when I rest"
+    - "gotta pause"
+    - "have to pause"
+    - "if I go too fast"
+    - "only if I rush"
+    - "only when I push too hard"
+    # --- historical / administrative context (FDA-safe) ---
+    - "years ago"
+    - "in the past"
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "routine check"
+    - "just a question"
+  # Changed from 'suppress' to 'downgrade_confidence' for FDA Non-Device CDS compliance.
+  # Baseline patterns reduce confidence rather than ruling out exertional origin.
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_has_condition: ["I50.*"]
+        patient_on_medication: ["furosemide", "bumetanide", "torsemide"]
+      reason: "CHF patient on diuretic -- dyspnea is decompensation signal"
+    - when:
+        patient_has_condition: ["J44.*"]
+        recent_lab:
+          code: "2160-0"
+          value_above: 1.5
+          within_days: 60
+      reason: "COPD patient with elevated creatinine -- cardiopulmonary concern"
+  boost_to_medium:
+    - when:
+        patient_has_condition: ["I50.*"]
+      reason: "CHF history raises concern for exertional dyspnea"
+    - when:
+        patient_has_condition: ["J44.*"]
+      reason: "COPD history raises concern for exertional dyspnea"
diff --git a/decision/taxonomy/fall_high_risk/flows/clarify.yaml b/decision/taxonomy/fall_high_risk/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e8ba41b6e1e1bcc6ee6204c116114f60a897ada0
--- /dev/null
+++ b/decision/taxonomy/fall_high_risk/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: fall_high_risk
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: fall_high_risk_clarify
+      goal: "Ask patient to describe their fall high risk symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - fall_high_risk_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/fall_high_risk/flows/escalate_r2.yaml b/decision/taxonomy/fall_high_risk/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0190cbdbbcbadc9e948572770ec162516423838a
--- /dev/null
+++ b/decision/taxonomy/fall_high_risk/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: fall_high_risk
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/fall_high_risk/flows/escalate_r3.yaml b/decision/taxonomy/fall_high_risk/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..501f66ee4d0458356d7aad14235a740a015eb9fc
--- /dev/null
+++ b/decision/taxonomy/fall_high_risk/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: fall_high_risk
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Instruct patient to call 911 immediately and inform them of nurse transfer"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/fall_high_risk/flows/handoff.yaml b/decision/taxonomy/fall_high_risk/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..25736914e3555d5f2a1bff05683d6b7b37508bd3
--- /dev/null
+++ b/decision/taxonomy/fall_high_risk/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: fall_high_risk
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: fall_high_risk_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: fall_high_risk_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/fall_high_risk/flows/reassure_low_risk.yaml b/decision/taxonomy/fall_high_risk/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..521987ab30ad9af225f336a3ec13c35e730d0c12
--- /dev/null
+++ b/decision/taxonomy/fall_high_risk/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: fall_high_risk
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: fall_high_risk_reassure
+      goal: "Acknowledge the patient's concern about their fall, note that their care team will be informed for routine follow-up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/fall_high_risk/flows/safety_screen.yaml b/decision/taxonomy/fall_high_risk/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9733118f6c2f2c9db509b3eb1f6dec2d1e086378
--- /dev/null
+++ b/decision/taxonomy/fall_high_risk/flows/safety_screen.yaml
@@ -0,0 +1,55 @@
+flow_id: safety_screen
+type: screening
+domain: fall_high_risk
+
+required_slots:
+  - head_strike
+  - on_anticoagulant
+  - injury_present
+  - loss_of_consciousness
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: fall_high_risk_screen_step1
+      goal: "Determine whether the fall involved head impact or injury"
+      tone: calm_urgent
+      must_include:
+        - "fall"
+      must_ask:
+        - "Did you hit your head during the fall?"
+        - "Do you have any injuries — cuts, bruises, or pain anywhere?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - head_strike
+      - injury_present
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: fall_high_risk_screen_step2
+      goal: "Screen for high-risk fall factors"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "Are you on any blood thinners or anticoagulant medications?"
+        - "Did you lose consciousness or black out at any point?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - on_anticoagulant
+      - loss_of_consciousness
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_r2: escalate_r2
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_r3
diff --git a/decision/taxonomy/fall_high_risk/rules.yaml b/decision/taxonomy/fall_high_risk/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d8ec15d4ca8a4fa690f02dbc2795938ea52cc51e
--- /dev/null
+++ b/decision/taxonomy/fall_high_risk/rules.yaml
@@ -0,0 +1,33 @@
+domain: fall_high_risk
+target_risk_class: R2
+
+decision_rules:
+  - id: fall_high_risk_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: fall_high_risk_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: fall_high_risk_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: fall_high_risk_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: fall_high_risk_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/fall_high_risk/triggers.yaml b/decision/taxonomy/fall_high_risk/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..83c28a9955a6d6d9afeeca9558139bd91ef4d63a
--- /dev/null
+++ b/decision/taxonomy/fall_high_risk/triggers.yaml
@@ -0,0 +1,192 @@
+domain: fall_high_risk
+priority: 76
+
+lexical_signals:
+  high:
+    phrases:
+      - 'fell and hit my head'
+      - 'fall on blood thinners'
+      - 'fell and I''m on anticoagulants'
+      - 'head strike from fall'
+      - 'fell and take warfarin'
+      - 'fell and hit my head while on anticoagulation'
+      - 'took a bad fall and hit my head'
+      - 'fell down the stairs'
+      - 'fell and can''t get up'
+      - 'fell and I take blood thinning tablets'
+      - 'dad fell and he is on warfarin'
+      - 'mum has fallen and bumped her head and she takes eliquis'
+      - 'had a fall and I''m confused and on blood thinners'
+      - 'fell and lost consciousness'
+      - 'fell and now can''t move my arm'
+      - 'fell off a ladder and hit my head'
+      - 'multiple falls this week'
+      - 'keeps falling over and over'
+      - 'fell and there is a big lump on the head'
+      - 'knocked out after a fall'
+      - 'fell and on apixaban'
+      - 'hit head on the floor when I collapsed'
+    regex:
+      - 'fell\s+and\s+(hit|struck)\s+(my\s+)?head'
+      - 'fall.*blood\s+thinner'
+      - '(fell|fall).{0,20}(warfarin|coumadin|eliquis|xarelto|apixaban|rivaroxaban|edoxaban|dabigatran|blood\s+thinner|anticoagul|thinn)'
+      - 'fell\s+(down\s+)?(the\s+)?stairs'
+      - '(fell|fall).{0,15}(can''?t|couldn''?t)\s+(get\s+)?up'
+      - '(fell|fall).{0,15}(lost|lose)\s+(conscious|awareness)'
+      - '(fell|fall).{0,15}(can''?t|couldn''?t)\s+(move|feel)\s+(my\s+)?(arm|leg|hand|foot|hip|wrist)'
+      - '(fell|fall|drop).{0,10}(off|from)\s+(a\s+)?(ladder|roof|height|chair|bed|stool)'
+      - '(multiple|several|keeps?|repeat).{0,10}(fall|fell|falling)'
+      - '(knocked?\s+out|unconscious|blacked?\s+out).{0,15}(fall|fell|hit)'
+      - '(head|skull|temple|forehead).{0,10}(hit|struck|crack|bang|bump).{0,15}(floor|ground|wall|table|concrete)'
+      - '(collapsed|fainted|passed\s+out).{0,15}(hit|struck|bump).{0,10}(head|skull|floor)'
+  medium:
+    phrases:
+      - 'fell and on blood thinners'
+      - 'took a fall and bumped my head'
+      - 'fell down and hit my head'
+      - 'lost balance and fell'
+      - 'fall with head injury'
+      - 'fell today on anticoagulants'
+      - 'fell in the bathroom'
+      - 'fell getting out of bed'
+      - 'fell off the chair'
+      - 'tripped and fell hard'
+      - 'slipped and fell'
+      - 'took a tumble'
+      - 'legs gave out'
+      - 'knees buckled and I went down'
+      - 'fell and something popped'
+      - 'went down hard'
+      - 'lost my balance'
+      - 'ground just came up'
+      - 'fell and my hip is really sore'
+      - 'fell and my wrist is swollen'
+      - 'nan had a fall in the care home'
+      - 'grandad has fallen again'
+      - 'found her on the floor'
+      - 'lying on the floor when I got home'
+      - 'fell and now feels sick and dizzy'
+      - 'hit the back of my head on the ground'
+      - 'landed on my face'
+      - 'slipped on ice and went flying'
+      - 'tripped on the rug and landed hard'
+      - 'blacked out and woke up on the floor'
+      - 'fell and there is a lot of bruising'
+      - 'fell and cut my head open'
+      - 'fell and my head is bleeding'
+      - 'can''t weight bear after the fall'
+      - 'hip gave way and I went down'
+      - 'feel unsteady and keep nearly falling'
+      - 'fell and feeling drowsy afterwards'
+      # --- MINIMIZER coverage ---
+      - "it wasn't a bad fall, just a little stumble"
+      - "I just tripped a bit, nothing serious"
+      - "barely fell, caught myself mostly"
+      - "just a minor spill"
+      - "I stumbled but I'm fine"
+      - "head might be a little sore"
+      - "just lost my balance for a second"
+      - "I just slipped a little"
+      - "bumped my head but I'm okay"
+      - "took a little tumble, nothing major"
+      - "I kind of went down but it wasn't that bad"
+      - "knee is a bit sore from a little fall"
+      - "wasn't really a fall, more of a stumble"
+      # --- additional caregiver report ---
+      - "he fell and won't get up"
+      - "she fell and is confused"
+      - "found him on the ground"
+    regex:
+      - '(fell|fall|tripped|slipped).{0,20}(hard|bad|badly|down|floor|ground|bathroom|kitchen|stairs)'
+      - '(legs?|knees?|balance).{0,15}(gave|buckl|lost|went)'
+      - '(took|had)\s+a\s+(bad\s+)?(fall|tumble|spill)'
+      - '(bump|hit|strike|crack|bang|smack).{0,15}(head|skull|forehead|temple)'
+      - '(fell|fall|down).{0,20}(bruise|swell|hurt|pain|sore|bleed|cut|gash)'
+      - '(lightheaded|dizzy|woozy|faint).{0,20}(fell|fall|went\s+down)'
+      - '(found|lying|lay).{0,10}(on\s+the\s+)?(floor|ground|pavement|carpet)'
+      - '(nan|nana|grandad|grandfather|grandmother|granny|gran|elderly).{0,20}(fell|fall|fallen|tumble)'
+      - '(fell|fall).{0,15}(hip|wrist|arm|shoulder|knee|ankle).{0,10}(sore|hurt|pain|swell|swollen)'
+      - '(black|pass).{0,5}(out|ed\s+out).{0,15}(floor|ground|woke\s+up)'
+      - '(fell|fall).{0,15}(cut|gash|lacerat|bleed).{0,10}(head|forehead|scalp|face)'
+      - '(can''?t|unable).{0,10}(weight\s+bear|stand|put\s+weight).{0,15}(fall|fell)'
+      - '(unsteady|wobbly|shaky).{0,15}(feet|legs?|walk|stand).{0,15}(fall|nearly)'
+      - '(drowsy|confused|sleepy|vomit).{0,15}(after|since|following).{0,10}(fall|fell|hit|bang)'
+      - '(slipped|tripped).{0,20}(ice|wet|rug|carpet|mat|curb|step|puddle|water|tile|floor)'
+      - '(head|skull|temple).{0,15}(bump|hit|struck|bang|smack).{0,15}(table|cabinet|furniture|counter|edge|shelf|wall)'
+      - '(apixaban|warfarin|eliquis|xarelto|blood\s+thinner|anticoagul).{0,100}(fell|fall|slip|trip|down|floor)'
+      - '(fell|fall|slip|trip|down|floor).{0,100}(apixaban|warfarin|eliquis|xarelto|blood\s+thinner|anticoagul)'
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(just|only).{0,10}(a\\s+)?(little|bit|minor|small|slight).{0,10}(fall|tumble|spill|stumble|trip|slip)"
+      - "(wasn'?t|not).{0,10}(a\\s+)?(bad|serious|real|big).{0,10}(fall|tumble|trip)"
+      - "(fell|tripped|slipped|stumbled).{0,15}(but|though).{0,15}(fine|okay|nothing|not that bad|not serious)"
+      - "(barely|almost|kind of|sort of).{0,10}(fell|tripped|went down|stumbled|slipped)"
+      - "(head|knee|hip|wrist|elbow).{0,15}(a\\s+)?(bit|little|kind of|sort of).{0,15}(sore|bruised|tender|achy).{0,15}(fall|fell|trip|stumble)"
+  low:
+    partials:
+      - 'fell'
+      - 'fall'
+      - 'head strike'
+      - 'anticoagulant fall'
+      - 'tripped'
+      - 'slipped'
+      - 'lost balance'
+      - 'went down'
+      - 'took a fall'
+      - 'tumble'
+      - 'found on floor'
+      - 'unsteady'
+      - 'wobbly on feet'
+      - 'collapse'
+      - 'blacked out'
+      - 'head bump'
+      - 'bruising after fall'
+      - 'mechanical fall'
+
+negation_handling:
+  patterns:
+    - 'didn''t fall'
+    - 'no falls'
+    - 'haven''t fallen'
+    - 'caught myself'
+    - 'almost fell but didn''t'
+    - 'no head injury'
+    - 'didn''t hit my head'
+    - 'no loss of consciousness'
+    - 'fall was weeks ago and fully recovered'
+    - 'not on any blood thinners'
+    - 'steady on feet'
+    - 'walking fine now'
+    - 'just stumbled but did not go down'
+    - 'grabbed the rail and caught myself'
+    - 'no bruising or swelling after the fall'
+    - 'head is fine after the bump'
+    - 'fall happened months ago'
+    - 'been checked after the fall and cleared'
+    - 'CT scan was normal after the fall'
+    - 'near miss but no actual fall'
+    - 'tripped but stayed on my feet'
+    # --- non-fall contexts (R1 scenarios) ---
+    - "falling behind"
+    - "fall behind"
+    - "fell behind"
+    - "fall prevention"
+    - "fall asleep"
+    - "fell asleep"
+    - "fall risk assessment"
+    - "fall into place"
+    - "fell into place"
+    - "downfall"
+    - "rainfall"
+    - "waterfall"
+    - "fall appointment"
+    - "fall cleanup"
+    - "fall season"
+    - "the fall"
+    - "last fall"
+    - "this fall"
+    - "in the fall"
+    - "fall through"
+    - "fall off the wagon"
+    - "let it fall"
+    - "fall back"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/febrile_neutropenia/flows/clarify.yaml b/decision/taxonomy/febrile_neutropenia/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1e6d3ba1073b117564e5f61d06f3d16f2d6676a3
--- /dev/null
+++ b/decision/taxonomy/febrile_neutropenia/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: febrile_neutropenia
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: febrile_neutropenia_clarify
+      goal: "Ask patient to describe their febrile neutropenia symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - febrile_neutropenia_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/febrile_neutropenia/flows/escalate_r3.yaml b/decision/taxonomy/febrile_neutropenia/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9614ec1978d92006d2de47e14a70fe6a5dab3d12
--- /dev/null
+++ b/decision/taxonomy/febrile_neutropenia/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: febrile_neutropenia
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Inform patient this requires immediate clinical attention and they will be transferred"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/febrile_neutropenia/flows/handoff.yaml b/decision/taxonomy/febrile_neutropenia/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9b337937749d04f16b1229154e1250fa3c6fea87
--- /dev/null
+++ b/decision/taxonomy/febrile_neutropenia/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: febrile_neutropenia
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: febrile_neutropenia_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: febrile_neutropenia_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/febrile_neutropenia/rules.yaml b/decision/taxonomy/febrile_neutropenia/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4f4d7d94ba2a3e6203930b14722a569bd1caf106
--- /dev/null
+++ b/decision/taxonomy/febrile_neutropenia/rules.yaml
@@ -0,0 +1,21 @@
+domain: febrile_neutropenia
+target_risk_class: R3
+
+decision_rules:
+  - id: febrile_neutropenia_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r3
+
+  - id: febrile_neutropenia_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r3
+
+  - id: febrile_neutropenia_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/febrile_neutropenia/triggers.yaml b/decision/taxonomy/febrile_neutropenia/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7c33e40c5cfe5d8e40f013ced0f96a52c6b76985
--- /dev/null
+++ b/decision/taxonomy/febrile_neutropenia/triggers.yaml
@@ -0,0 +1,65 @@
+domain: febrile_neutropenia
+priority: 85
+
+lexical_signals:
+  high:
+    phrases:
+      - "fever and just had chemo"
+      - "neutropenic fever"
+      - "febrile neutropenia"
+      - "fever with low white count"
+      - "temperature 101 and on chemotherapy"
+      - "high fever after cancer treatment"
+      - "fever and on chemo"
+      - "chills and on chemo"
+    regex:
+      - "(febrile|fever)\\s+(and\\s+)?neutrop"
+      - "fever\\s+(after|and|during)\\s+chemo"
+      - "(fever|temperature|temp).{0,40}(chemo|chemotherapy|cancer treatment|oncolog)"
+      - "(chemo|chemotherapy|cancer treatment).{0,40}(fever|temperature|temp|101|102|103|38)"
+      - "(chills|shaking|shiver).{0,40}(chemo|chemotherapy|cancer treatment)"
+      # --- chemo + fever combination ---
+      - "(fever|temp|temperature).{0,30}(since|after|following).{0,20}(treatment|infusion|session)"
+      - "(got|have|running|developed).{0,15}(a )?fever.{0,30}(chemo|chemotherapy|treatment)"
+      - "(last|recent).{0,15}(chemo|chemotherapy|treatment).{0,30}(fever|temp|temperature)"
+      # --- immunocompromised context ---
+      - "(on|receiving|getting|having).{0,15}(chemo|chemotherapy).{0,30}(and|with).{0,15}(fever|temp|temperature)"
+      - "(low|no|depleted).{0,15}(white|wbc|immune|blood).{0,20}(count|cells?|system).{0,30}(fever|temp)"
+      - "(fever|temp).{0,30}(low|no|depleted).{0,15}(white|wbc|immune|blood).{0,20}(count|cells?|system)"
+      - "(immunocompromised|immunosuppressed|weak immune).{0,30}(fever|temp|temperature|101|102)"
+      # --- urgency language ---
+      - "(oncologist|doctor|nurse|they).{0,20}(said|told|warned).{0,30}(call|come in|emergency).{0,20}(if|when).{0,15}fever"
+      - "(told|said|warned).{0,20}fever.{0,20}(emergency|serious|dangerous|urgent|come in|call)"
+      - "fever.{0,20}(emergency|serious|dangerous).{0,20}(with|on|during).{0,20}(chemo|chemotherapy|treatment)"
+      - "(any|even a little|slight).{0,10}fever.{0,30}(chemo|chemotherapy|treatment)"
+  medium:
+    phrases:
+      - "fever after chemo"
+      - "chills and on chemotherapy"
+      - "temperature up and immunosuppressed"
+      - "fever and immunocompromised"
+      - "fever on cancer treatment"
+      - "took my temperature twice"
+      - "running a fever and on chemo"
+      - "101 degrees and on chemotherapy"
+      - "102 degrees after chemo"
+    regex:
+      - "(immunosuppress|immunocompromis).{0,30}(fever|temp|101|102)"
+      - "(fever|temp).{0,30}(immunosuppress|immunocompromis)"
+      - "on\\s+(chemo|chemotherapy).{0,40}(fever|temperature|chills)"
+      - "(101|102|103|38\\.[0-9]).*chemo"
+      - "chemo.*(101|102|103|38\\.[0-9])"
+  low:
+    partials:
+      - "neutropenic"
+      - "chemo fever"
+      - "immunosuppressed fever"
+      - "on chemotherapy"
+      - "cancer treatment"
+
+negation_handling:
+  patterns:
+    - "no fever"
+    - "temperature normal"
+    - "feeling fine after chemo"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/food_insecurity/flows/clarify.yaml b/decision/taxonomy/food_insecurity/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d0ad2d137a1f1bacd33a165ad0440b04eb4b1b20
--- /dev/null
+++ b/decision/taxonomy/food_insecurity/flows/clarify.yaml
@@ -0,0 +1,26 @@
+flow_id: clarify
+type: clarification
+domain: food_insecurity
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: food_insecurity_clarify
+      goal: "Ask the patient to tell more about their food access situation"
+      tone: warm_empathetic
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "charity"
+        - "welfare"
+        - "poor"
+      max_questions: 1
+    collects:
+      - food_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/food_insecurity/flows/community_resource_referral.yaml b/decision/taxonomy/food_insecurity/flows/community_resource_referral.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..506a3e13638b8794bd0176f14b6521679bee8800
--- /dev/null
+++ b/decision/taxonomy/food_insecurity/flows/community_resource_referral.yaml
@@ -0,0 +1,24 @@
+flow_id: community_resource_referral
+type: resolution
+domain: food_insecurity
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: food_community_resource_referral
+      goal: "Inform the patient that their care team will connect them with food assistance resources in their community"
+      tone: warm_empathetic
+      must_include:
+        - "care team"
+        - "resources"
+        - "food"
+      must_not:
+        - "charity"
+        - "welfare"
+        - "poor"
+        - "handout"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/food_insecurity/flows/food_screen.yaml b/decision/taxonomy/food_insecurity/flows/food_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5bb05828a493b84d47dca129b7e471d6b142a64a
--- /dev/null
+++ b/decision/taxonomy/food_insecurity/flows/food_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: food_screen
+type: screening
+domain: food_insecurity
+
+required_slots:
+  - food_access
+  - household_size
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: food_screen_step1
+      goal: "Assess the severity of food access issues and household composition"
+      tone: warm_empathetic
+      must_include:
+        - "food"
+      must_ask:
+        - "Can you tell me more about what's going on with your food situation?"
+        - "How many people are in your household?"
+      must_not:
+        - "charity"
+        - "welfare"
+        - "poor"
+        - "can't afford"
+      max_questions: 2
+    collects:
+      - food_access
+      - household_size
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: food_screen_step2
+      goal: "Ask about current assistance programs enrollment"
+      tone: warm_empathetic
+      must_include:
+        - "help"
+      must_ask:
+        - "Are you currently enrolled in any food assistance programs?"
+      must_not:
+        - "welfare"
+        - "handout"
+        - "charity"
+      max_questions: 1
+    collects:
+      - snap_enrolled
+
+exit:
+  on_complete: evaluate_concern
+  on_concern: community_resource_referral
+  on_low_risk: community_resource_referral
+  on_unclear: community_resource_referral
diff --git a/decision/taxonomy/food_insecurity/rules.yaml b/decision/taxonomy/food_insecurity/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..cb5ab02d052c2908e220e206b3abd5f8d815bd89
--- /dev/null
+++ b/decision/taxonomy/food_insecurity/rules.yaml
@@ -0,0 +1,27 @@
+domain: food_insecurity
+target_risk_class: R1
+
+decision_rules:
+  - id: food_insecurity_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: food_screen
+
+  - id: food_insecurity_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: food_screen
+
+  - id: food_insecurity_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: food_insecurity_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: community_resource_referral
diff --git a/decision/taxonomy/food_insecurity/triggers.yaml b/decision/taxonomy/food_insecurity/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..98ac0803684e0aae89aa3c6e8653d17ad92746ef
--- /dev/null
+++ b/decision/taxonomy/food_insecurity/triggers.yaml
@@ -0,0 +1,75 @@
+domain: food_insecurity
+priority: 33
+
+lexical_signals:
+  high:
+    phrases:
+      - "can't afford food"
+      - "skipping meals because I can't afford them"
+      - "running out of food"
+      - "not enough to eat"
+      - "kids are going hungry"
+      - "go to bed hungry"
+      - "haven't eaten in days"
+      - "no money for groceries"
+      - "choosing between food and medicine"
+      - "can't feed my family"
+      - "food bank ran out"
+      - "rationing food"
+      - "cutting back meals to afford rent"
+      - "no food in the house"
+    regex:
+      - "(can't|cannot|unable\\s+to)\\s+(afford|buy|get).{0,15}(food|groceries|meals|enough\\s+to\\s+eat)"
+      - "(skipping|skip|miss|missing)\\s+meals?.{0,15}(can't\\s+afford|no\\s+money|cost)"
+      - "(running|ran)\\s+out\\s+of.{0,10}(food|groceries)"
+      - "(not\\s+enough|no\\s+money\\s+for|can't\\s+pay\\s+for).{0,10}(food|groceries|meals|to\\s+eat)"
+      - "(go|going)\\s+to\\s+bed.{0,10}(hungry|without\\s+eating)"
+      - "(choosing|choose)\\s+between.{0,15}(food|medicine|medication|rent|bills)"
+  medium:
+    phrases:
+      - "skipping meals"
+      - "food bank"
+      - "hungry a lot"
+      - "food stamps"
+      - "need help with food"
+      - "can't get enough food"
+      - "groceries are too expensive"
+      - "struggling to eat"
+      - "worried about food"
+      - "food pantry"
+      - "SNAP benefits"
+      - "running low on food"
+      - "WIC"
+      - "meals on wheels"
+    regex:
+      - "(skip|skipping|missing)\\s+(meals?|breakfast|lunch|dinner)"
+      - "(food|grocery).{0,10}(bank|pantry|stamps|assistance|help)"
+      - "(hungry|hunger).{0,10}(a\\s+lot|often|frequently|all\\s+the\\s+time)"
+      - "(struggling|trouble|hard\\s+time).{0,10}(eat|afford|get).{0,10}(food|meals|groceries)"
+  low:
+    partials:
+      - "hungry"
+      - "food"
+      - "groceries"
+      - "meals"
+      - "food stamps"
+
+negation_handling:
+  patterns:
+    - "have enough food"
+    - "eating well"
+    - "no food issues"
+    - "groceries are fine"
+    - "eating three meals a day"
+    - "plenty of food"
+    - "food is not a problem"
+    - "well fed"
+    - "stocked up on food"
+    - "no trouble with food"
+    - "eating regularly"
+    - "food situation is fine"
+    - "not hungry"
+    - "getting enough to eat"
+    - "meals are covered"
+    - "no issues with food"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/gi_bleed/flows/clarify.yaml b/decision/taxonomy/gi_bleed/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..235ed1c0c2703390856b9e20a67b0e2b6f42c6bd
--- /dev/null
+++ b/decision/taxonomy/gi_bleed/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: gi_bleed
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: gi_bleed_clarify
+      goal: "Ask patient to describe their gi bleed symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - gi_bleed_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/gi_bleed/flows/escalate_r2.yaml b/decision/taxonomy/gi_bleed/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8446996e163f6cc99a91863e910aa93db8307b12
--- /dev/null
+++ b/decision/taxonomy/gi_bleed/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: gi_bleed
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/gi_bleed/flows/escalate_r3.yaml b/decision/taxonomy/gi_bleed/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..54ace1735b3720a71c12d8ecfe96e498fd9061b7
--- /dev/null
+++ b/decision/taxonomy/gi_bleed/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: gi_bleed
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Instruct patient to call 911 immediately and inform them of nurse transfer"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/gi_bleed/flows/handoff.yaml b/decision/taxonomy/gi_bleed/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..877d14ae003e17a3032966cb7935b4401a8aea79
--- /dev/null
+++ b/decision/taxonomy/gi_bleed/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: gi_bleed
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: gi_bleed_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: gi_bleed_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/gi_bleed/flows/safety_screen.yaml b/decision/taxonomy/gi_bleed/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7abf1deec316678021e888ba9c617a78b7ae743c
--- /dev/null
+++ b/decision/taxonomy/gi_bleed/flows/safety_screen.yaml
@@ -0,0 +1,54 @@
+flow_id: safety_screen
+type: screening
+domain: gi_bleed
+
+required_slots:
+  - blood_color
+  - blood_amount
+  - stool_appearance
+  - associated_symptoms
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "blood color"
+        - "blood amount"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - blood_color
+      - blood_amount
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "stool appearance"
+        - "associated symptoms"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - stool_appearance
+      - associated_symptoms
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/decision/taxonomy/gi_bleed/rules.yaml b/decision/taxonomy/gi_bleed/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ee7f21a606047dd59eeceaf6aa1af349fcacb9ab
--- /dev/null
+++ b/decision/taxonomy/gi_bleed/rules.yaml
@@ -0,0 +1,33 @@
+domain: gi_bleed
+target_risk_class: R3
+
+decision_rules:
+  - id: gi_bleed_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: gi_bleed_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: gi_bleed_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: gi_bleed_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: gi_bleed_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/gi_bleed/triggers.yaml b/decision/taxonomy/gi_bleed/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ea418a823caa551ad3500b8f623b384cfbdc9703
--- /dev/null
+++ b/decision/taxonomy/gi_bleed/triggers.yaml
@@ -0,0 +1,184 @@
+domain: gi_bleed
+priority: 80
+
+lexical_signals:
+  high:
+    phrases:
+      # --- original ---
+      - "vomiting blood"
+      - "black tarry stool"
+      - "blood in vomit"
+      - "hematemesis"
+      - "melena"
+      - "bloody stool"
+      - "bright red blood in stool"
+      # --- expanded naturalistic ---
+      - "throwing up blood"
+      - "puking blood"
+      - "coffee ground vomit"
+      - "vomit looks like coffee grounds"
+      - "threw up and it was all blood"
+      - "blood coming up when I vomit"
+      - "bright red blood coming out of my rectum"
+      - "large amount of blood from my bottom"
+      - "passing blood clots from my rectum"
+      - "blood clots in my stool"
+      - "hemorrhaging from my stomach"
+      - "GI hemorrhage"
+      - "massive rectal bleeding"
+      - "stool is pure blood"
+      - "toilet bowl full of blood after bowel movement"
+      - "pooping nothing but blood"
+      - "vomited a large amount of blood"
+      - "maroon colored stool with clots"
+      - "blood pouring from my backside"
+    regex:
+      # --- original ---
+      - "(vomiting|throwing\\s+up)\\s+blood"
+      - "(black|bloody|tarry)\\s+stool"
+      - "(hematemesis|melena)"
+      # --- expanded ---
+      - "(puking|spitting|coughing)\\s+up\\s+blood"
+      - "coffee\\s+ground(s)?\\s+(vomit|emesis|puke)"
+      - "vomit.*(coffee\\s+ground|dark\\s+brown\\s+blood|looks\\s+like\\s+blood)"
+      - "bright\\s+red\\s+blood\\s+(in|from|with)\\s+(stool|rectum|bowel|bottom)"
+      - "(massive|large|heavy|significant)\\s+(amount\\s+of\\s+)?(rectal\\s+)?bleed(ing)?"
+      - "blood\\s+clot(s)?\\s+(in|from|with)\\s+(stool|rectum|bowel)"
+      - "(hemorrhag|GI\\s+bleed|gastrointestinal\\s+bleed)"
+      - "stool\\s+(is\\s+)?(pure|all|nothing\\s+but)\\s+blood"
+      - "toilet\\s+(bowl\\s+)?(full|covered)\\s+(of|with|in)\\s+blood"
+      - "(pooping|passing|having)\\s+(nothing\\s+but|only|pure)\\s+blood"
+      - "threw\\s+up.*(blood|red|coffee)"
+      - "maroon\\s+(colored\\s+)?stool"
+      # --- additional euphemistic ---
+      - "(dark|black)\\s+(stuff|liquid|substance).{0,15}(came up|vomit|threw)"
+  medium:
+    phrases:
+      # --- original ---
+      - "blood when I throw up"
+      - "stool looks very dark"
+      - "noticed blood after vomiting"
+      - "dark stools since discharge"
+      - "rectal bleeding"
+      - "blood streaks in stool"
+      # --- expanded naturalistic ---
+      - "blood in my stool"
+      - "dark stools"
+      - "stools are really dark"
+      - "blood on toilet paper after wiping"
+      - "blood when I wipe"
+      - "passing some blood with bowel movements"
+      - "my bowels are bloody"
+      - "stomach is bleeding"
+      - "some blood mixed in my stool"
+      - "small amount of blood in stool"
+      - "noticed blood in the toilet"
+      - "poop has blood in it"
+      - "dark red blood in stool"
+      - "blood dripping after a bowel movement"
+      - "stools have gotten very dark and sticky"
+      - "my stool is black"
+      - "tar-like stool"
+      - "stool smells metallic and is dark"
+      - "blood spots in my stool"
+      - "I see blood when I go to the bathroom"
+      - "bloody mucus in stool"
+      - "there was blood on the tissue"
+      - "a little blood in my stool"
+      - "traces of blood in bowel movement"
+      - "spotting blood from my rectum"
+      - "my stool has a reddish tinge"
+      - "vomit had some blood in it"
+      - "pink-tinged vomit"
+    regex:
+      - "blood\\s+(on|when)\\s+(the\\s+)?(toilet\\s+paper|tissue|wip)"
+      - "(dark|black|tar|tarry|sticky)\\s+(colored\\s+)?stool(s)?"
+      - "blood\\s+(in|mixed|with|from)\\s+(the\\s+)?(stool|bowel|toilet|poop)"
+      - "(some|small|little|bit\\s+of)\\s+blood\\s+(in|from|with)"
+      - "(passing|spotting|dripping|seeing)\\s+blood\\s+(from|with|during|after)"
+      - "bowel(s)?\\s+(are\\s+)?blood"
+      - "stomach\\s+(is\\s+)?bleed"
+      - "(rectal|anal|bottom)\\s+bleed"
+      - "stool.*(reddish|red|maroon|dark)"
+      - "(bloody|blood)\\s+mucus\\s+(in\\s+)?stool"
+      - "pink\\s*(-)?\\s*tinged\\s+vomit"
+      - "vomit\\s+had\\s+(some\\s+)?blood"
+      - "(bright\\s+red|red).{0,15}(wip|paper|toilet|tissue)"
+      - "clots?.{0,15}(jelly|small|couple|grape|pea)"
+      - "(toilet|water).{0,15}(red|tinted|blood|swirl)"
+      - "(blackish|darkish|almost\\s+black).{0,15}(sticky|stool|poop)"
+      - "(darker\\s+than\\s+normal|darker\\s+than\\s+usual).{0,20}(sticky|black|tar)"
+    partials:
+      - "melena"
+      - "rectal bleeding"
+      - "blood in stool"
+      - "dark stool"
+      - "hematochezia"
+      - "GI blood"
+      - "bloody bowel"
+  low:
+    partials:
+      # --- original ---
+      - "blood in stool"
+      - "dark stool"
+      - "rectal bleeding"
+      # --- expanded ---
+      - "hematemesis"
+      - "hematochezia"
+      - "melena"
+      - "GI bleed"
+      - "GI bleeding"
+      - "GI hemorrhage"
+      - "upper GI bleed"
+      - "lower GI bleed"
+      - "gastrointestinal bleed"
+      - "gastrointestinal hemorrhage"
+      - "rectal blood"
+      - "bloody emesis"
+      - "coffee ground emesis"
+      - "occult blood"
+      - "fecal blood"
+      - "varices bleeding"
+      - "esophageal bleed"
+      - "anal bleeding"
+
+negation_handling:
+  patterns:
+    # --- original ---
+    - "no blood in stool"
+    - "no vomiting blood"
+    - "stools normal color"
+    # --- expanded ---
+    - "hemorrhoids diagnosed"
+    - "small streak of blood"
+    - "bleeding stopped"
+    - "stool sample normal"
+    - "stool test came back negative"
+    - "no signs of GI bleeding"
+    - "bleeding resolved on its own"
+    - "no active bleeding"
+    - "hemorrhoid flare up"
+    - "just a little hemorrhoid bleeding"
+    - "blood was from a fissure"
+    - "anal fissure causing the blood"
+    - "no more blood in stool"
+    - "colonoscopy was normal"
+    - "occult blood test negative"
+    - "stool guaiac negative"
+    - "no melena or hematemesis"
+    - "dark stool from iron supplements"
+    - "stool dark from medication"
+    - "bleeding from external hemorrhoid only"
+    - "no rectal bleeding"
+    - "bowel movements back to normal"
+    - "no blood noted"
+    - "stools are normal now"
+    - "vomiting but no blood"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/glucose_out_of_range/flows/clarify.yaml b/decision/taxonomy/glucose_out_of_range/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..777b391dd1f6802a0ad76323123f27604f78d18d
--- /dev/null
+++ b/decision/taxonomy/glucose_out_of_range/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: glucose_out_of_range
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: glucose_out_of_range_clarify
+      goal: "Ask patient to describe their glucose out of range symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - glucose_out_of_range_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/glucose_out_of_range/flows/escalate_r1.yaml b/decision/taxonomy/glucose_out_of_range/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..bb90cc373d97b4176bdb305052e346aada6b0fe8
--- /dev/null
+++ b/decision/taxonomy/glucose_out_of_range/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: glucose_out_of_range
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/glucose_out_of_range/flows/handoff.yaml b/decision/taxonomy/glucose_out_of_range/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c52ea82c5e59779071ed8b71425777d7b05ebc07
--- /dev/null
+++ b/decision/taxonomy/glucose_out_of_range/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: glucose_out_of_range
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: glucose_out_of_range_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: glucose_out_of_range_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/glucose_out_of_range/rules.yaml b/decision/taxonomy/glucose_out_of_range/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e650c6633d4e12f82391a0c0381a3ab85d83965c
--- /dev/null
+++ b/decision/taxonomy/glucose_out_of_range/rules.yaml
@@ -0,0 +1,21 @@
+domain: glucose_out_of_range
+target_risk_class: R1
+
+decision_rules:
+  - id: glucose_out_of_range_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r1
+
+  - id: glucose_out_of_range_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r1
+
+  - id: glucose_out_of_range_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/glucose_out_of_range/triggers.yaml b/decision/taxonomy/glucose_out_of_range/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a4fe758c5ebe1a51ce355d2c128bce051017eea0
--- /dev/null
+++ b/decision/taxonomy/glucose_out_of_range/triggers.yaml
@@ -0,0 +1,34 @@
+domain: glucose_out_of_range
+priority: 40
+
+lexical_signals:
+  high:
+    phrases:
+      - "blood sugar staying above 300"
+      - "glucose readings consistently high"
+      - "sugar won't come down to normal"
+      - "blood sugar all over the place"
+      - "glucose persistently elevated"
+      - "blood sugar out of range for days"
+    regex:
+      - "(blood\\s+sugar|glucose).*(above\\s+[23]\\d{2}|out\\s+of\\s+range|persistently)"
+  medium:
+    phrases:
+      - "blood sugar readings are high"
+      - "sugar above normal range"
+      - "glucose not well controlled"
+      - "sugar running higher than target"
+      - "blood sugar fluctuating a lot"
+  low:
+    partials:
+      - "blood sugar"
+      - "glucose"
+      - "sugar levels"
+      - "A1C"
+
+negation_handling:
+  patterns:
+    - "blood sugar normal"
+    - "glucose controlled"
+    - "sugar in range"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/heart_failure_worsening/flows/clarify.yaml b/decision/taxonomy/heart_failure_worsening/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..573104168682696f5c8f441a0b6a00aecacbb697
--- /dev/null
+++ b/decision/taxonomy/heart_failure_worsening/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: heart_failure_worsening
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: heart_failure_worsening_clarify
+      goal: "Ask patient to describe their heart failure worsening symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - heart_failure_worsening_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/heart_failure_worsening/flows/escalate_r2.yaml b/decision/taxonomy/heart_failure_worsening/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..971d7b905624163a2719f3e82a7b94aca3d4596d
--- /dev/null
+++ b/decision/taxonomy/heart_failure_worsening/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: heart_failure_worsening
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/heart_failure_worsening/flows/handoff.yaml b/decision/taxonomy/heart_failure_worsening/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4043cf16546af5cffa08a51f4f35fbaa527447f4
--- /dev/null
+++ b/decision/taxonomy/heart_failure_worsening/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: heart_failure_worsening
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: heart_failure_worsening_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: heart_failure_worsening_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/heart_failure_worsening/flows/safety_screen.yaml b/decision/taxonomy/heart_failure_worsening/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0af2ca15bdce78b8bbf13277111958a1c8837661
--- /dev/null
+++ b/decision/taxonomy/heart_failure_worsening/flows/safety_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: safety_screen
+type: screening
+domain: heart_failure_worsening
+
+required_slots:
+  - weight_change
+  - edema_severity
+  - breathing_status
+  - activity_tolerance
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "weight change"
+        - "edema severity"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - weight_change
+      - edema_severity
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "breathing status"
+        - "activity tolerance"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - breathing_status
+      - activity_tolerance
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/decision/taxonomy/heart_failure_worsening/rules.yaml b/decision/taxonomy/heart_failure_worsening/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..15a3653bbb2ee09f154d669e2fba7aa3356e5adc
--- /dev/null
+++ b/decision/taxonomy/heart_failure_worsening/rules.yaml
@@ -0,0 +1,27 @@
+domain: heart_failure_worsening
+target_risk_class: R2
+
+decision_rules:
+  - id: heart_failure_worsening_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: heart_failure_worsening_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: heart_failure_worsening_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: heart_failure_worsening_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/heart_failure_worsening/triggers.yaml b/decision/taxonomy/heart_failure_worsening/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d6b0e25c1e49692ec1bd83dd1b5174ec41f9f01d
--- /dev/null
+++ b/decision/taxonomy/heart_failure_worsening/triggers.yaml
@@ -0,0 +1,183 @@
+domain: heart_failure_worsening
+priority: 74
+
+lexical_signals:
+  high:
+    phrases:
+      - 'can''t lie flat to breathe'
+      - 'legs swelling up rapidly'
+      - 'gaining weight rapidly and short of breath'
+      - 'paroxysmal nocturnal dyspnea'
+      - 'waking up gasping for air'
+      - 'heart failure getting worse'
+      - 'short of breath and legs swelling'
+      - 'can''t breathe lying down'
+      - 'feet are really swollen and I''m short of breath'
+      - 'gained 5 pounds in two days'
+      - 'ankles are huge and I can''t catch my breath'
+      - 'heart failure flare up'
+      - 'legs like tree trunks and breathing is terrible'
+      - 'had to sleep sitting in a chair because I couldn''t breathe'
+      - 'put on half a stone in a week and can''t walk to the toilet'
+      - 'my heart failure is decompensating'
+      - 'fluid overload symptoms getting worse'
+      - 'can''t even walk to the kitchen without stopping for breath'
+      - 'woke up choking and my legs are massive'
+      - 'been told I have heart failure and now my legs are swelling badly'
+    regex:
+      - '(heart\s+failure|CHF).*(worse|worsen|getting|flare|decompens)'
+      - 'can''?t\s+lie\s+flat'
+      - '(short\s+of\s+breath|can''?t\s+breathe).{0,30}(swell|edema|ankle|leg|feet|weight)'
+      - '(swell|edema|ankle|leg|feet).{0,30}(short\s+of\s+breath|can''?t\s+breathe|winded)'
+      - 'gained?\s+\d+\s+(pound|lb|kg|stone).{0,20}(day|week|few|couple)'
+      - '(wak|wake|woke).{0,15}(gasp|can''?t\s+breathe|short\s+of\s+breath|choking)'
+      - '(sleep|slept).{0,15}(chair|sitting|upright|propped).{0,20}(can''?t\s+breathe|breath)'
+      - '(can''?t|unable\s+to).{0,10}(walk|move).{0,20}(breath|wind|puff)'
+      - '(fluid\s+overload|decompens).{0,20}(worse|symptom|getting)'
+      - '(massive|huge|enormous).{0,10}(leg|ankle|feet|foot).{0,20}(breath|wind|puff)'
+  medium:
+    phrases:
+      - 'more swollen ankles than before'
+      - 'more short of breath than usual'
+      - 'gained several pounds in a week'
+      - 'increasing leg edema'
+      - 'worsening heart failure symptoms'
+      - 'needing more pillows to sleep'
+      - 'ankles are puffier'
+      - 'shoes don''t fit anymore'
+      - 'rings are tight'
+      - 'feet look like balloons'
+      - 'breathing is harder than usual'
+      - 'winded doing simple things'
+      - 'can''t walk as far as I used to'
+      - 'out of breath more easily'
+      - 'socks leaving marks'
+      - 'legs feel heavy and swollen'
+      - 'pitting when I press'
+      - 'belly feels bloated and tight'
+      - 'weight keeps going up'
+      - 'putting on water weight'
+      - 'sleeping propped up'
+      - 'waking up short of breath'
+      - 'ankles swollen up over my socks'
+      - 'skin feels tight on my legs'
+      - 'can feel the fluid in my legs'
+      - 'calves are rock hard'
+      - 'weighed myself and I am up four pounds'
+      - 'breathing is getting worse day by day'
+      - 'had to stop halfway up the stairs to catch my breath'
+      - 'peeing less than normal'
+      - 'tummy is swollen and hard'
+      - 'can''t bend my ankles properly because of the swelling'
+      - 'went up two notches on my belt'
+      - 'face looks puffy in the morning'
+      - 'fingers are like sausages'
+      - 'clothes are getting tighter but I haven''t been eating more'
+      - 'coughing more when I lie down'
+      - 'pink frothy sputum'
+      - 'wheezing at night in bed'
+      # --- MINIMIZER coverage ---
+      - "swelling, I wouldn't call it swelling, just a little puffiness"
+      - "sleeping on two pillows because it's more comfy"
+      - "shoes feel different sometimes"
+      - "socks leave marks"
+      - "ankles look sort of like they disappeared"
+      - "I notice when I lie flat I feel sort of heavy in my chest"
+      - "gained a little weight but probably just eating more"
+      - "a bit more winded than usual"
+      - "breathing is just a little harder lately"
+    regex:
+      - '(ankle|leg|feet|foot).{0,20}(swell|swollen|puffy|puff|balloon|edema|bigger|heavy)'
+      - '(swell|swollen|puffy|puff).{0,20}(ankle|leg|feet|foot)'
+      - '(shoe|ring|sock|belt|clothes).{0,15}(tight|don''?t\s+fit|leaving\s+mark|cutting|notch)'
+      - '(breath|breathing|winded|breathless).{0,20}(worse|harder|more|easily|usual|than\s+before)'
+      - '(weight|weigh).{0,15}(gain|up|going\s+up|higher|more)'
+      - '(sleep|sleeping|night).{0,20}(prop|pillow|upright|sit\s+up|can''?t\s+lie)'
+      - '(pit|pitting|indent).{0,15}(press|push|finger)'
+      - '(belly|abdomen|stomach|tummy).{0,15}(bloat|tight|distend|swell|hard)'
+      - '(skin|leg|ankle).{0,15}(tight|shiny|stretch|hard).{0,15}(swell|fluid|edema)'
+      - '(pee|urin).{0,15}(less|barely|hardly|not\s+much|reduced)'
+      - '(face|finger|hand).{0,15}(puffy|swell|swollen|sausage|bloat)'
+      - '(cough|wheez).{0,15}(lie|lying|bed|night|flat|down)'
+      - '(pink|frothy|foamy).{0,15}(sputum|phlegm|mucus|cough)'
+      - '(stair|walk|step).{0,15}(stop|rest|breath|wind|puff|gasp)'
+      - '(up|gained)\s+\d+\s+(pound|lb|kg|notch)'
+      - '(fluid|water).{0,15}(retention|retain|holding|build)'
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - '(just|only).{0,10}(a\s+)?(little|bit|slight).{0,10}(puff|swell|bloat|winded|breathless|short of breath|weight|heavier)'
+      - '(shoes?|socks?|rings?|belt).{0,15}(tight|tighter|snug|different|don''t fit|leave marks|digging in)'
+      - '(probably|might be).{0,10}(just|nothing|eating|salt|water|normal).{0,20}(swell|puff|weight|bloat|ankle)'
+      - '(pillow|sleep|lying).{0,15}(extra|two|more|propped|flat).{0,15}(breath|comfy|easier|heavy|chest)'
+      - '(ankle|leg|feet|foot).{0,15}(a\s+)?(bit|little|kind of|sort of).{0,15}(puffy|swollen|big|thick|heavy)'
+  low:
+    partials:
+      - 'heart failure'
+      - 'edema worsening'
+      - 'CHF'
+      - 'orthopnea'
+      - 'swollen ankles'
+      - 'swollen feet'
+      - 'swollen legs'
+      - 'can''t lie flat'
+      - 'gaining weight'
+      - 'water retention'
+      - 'fluid retention'
+      - 'puffy ankles'
+      - 'breathless'
+      - 'winded easily'
+      - 'extra pillows'
+      - 'pitting edema'
+      - 'tight shoes'
+      - 'coughing at night'
+      - 'fluid on lungs'
+      - 'congestion'
+
+negation_handling:
+  patterns:
+    - 'heart failure stable'
+    - 'swelling unchanged'
+    - 'no worsening symptoms'
+    - 'swelling went down'
+    - 'breathing better'
+    - 'weight stable'
+    - 'swelling is the same as usual'
+    - 'ankles have gone down'
+    - 'legs are back to normal'
+    - 'breathing has improved'
+    - 'sleeping flat again'
+    - 'no new swelling'
+    - 'weight has come back down'
+    - 'diuretics are working well'
+    - 'fluid has shifted'
+    - 'walking further than before'
+    - 'heart failure well controlled'
+    - 'no change in weight'
+    - 'swelling comes and goes but is not worse'
+    - 'shoes fit fine now'
+    - 'can lie flat without problems'
+    # --- administrative context (suppress) ---
+    - 'schedule an appointment'
+    - 'follow-up appointment'
+    - 'appointment timing'
+    - 'routine check'
+    - 'just a question'
+    - 'medication refill'
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_has_condition: ["I50.*"]
+        patient_on_medication: ["furosemide", "bumetanide", "torsemide"]
+      reason: "CHF patient on diuretic -- swelling is decompensation signal"
+    - when:
+        patient_has_condition: ["I50.*"]
+        recent_lab:
+          code: "42637-9"
+          value_above: 400
+          within_days: 30
+      reason: "CHF patient with elevated BNP -- fluid overload likely"
+  boost_to_medium:
+    - when:
+        patient_has_condition: ["I50.*"]
+      reason: "CHF history alone raises baseline concern for swelling"
diff --git a/decision/taxonomy/homicidal_ideation/flows/clarify.yaml b/decision/taxonomy/homicidal_ideation/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e39bcd1d82195fadb7b02a079b07baaea800e26c
--- /dev/null
+++ b/decision/taxonomy/homicidal_ideation/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: homicidal_ideation
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: homicidal_ideation_clarify
+      goal: "Ask patient to describe their homicidal ideation symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - homicidal_ideation_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/homicidal_ideation/flows/escalate_r3.yaml b/decision/taxonomy/homicidal_ideation/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8ff779f8d9655eb76fa8756535629a28f7ea9a62
--- /dev/null
+++ b/decision/taxonomy/homicidal_ideation/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: homicidal_ideation
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Inform patient this requires immediate clinical attention and they will be transferred"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/homicidal_ideation/flows/handoff.yaml b/decision/taxonomy/homicidal_ideation/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..051f728fa28fee1245b6a8bc3810ffe838f8f420
--- /dev/null
+++ b/decision/taxonomy/homicidal_ideation/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: homicidal_ideation
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: homicidal_ideation_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: homicidal_ideation_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/homicidal_ideation/rules.yaml b/decision/taxonomy/homicidal_ideation/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..04fd10c61f2a877b2058cb3ba277d7b0b203dd6e
--- /dev/null
+++ b/decision/taxonomy/homicidal_ideation/rules.yaml
@@ -0,0 +1,21 @@
+domain: homicidal_ideation
+target_risk_class: R3
+
+decision_rules:
+  - id: homicidal_ideation_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r3
+
+  - id: homicidal_ideation_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r3
+
+  - id: homicidal_ideation_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/homicidal_ideation/triggers.yaml b/decision/taxonomy/homicidal_ideation/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ada7350e38d5a07bc4d6babeb92b09c187ed2f23
--- /dev/null
+++ b/decision/taxonomy/homicidal_ideation/triggers.yaml
@@ -0,0 +1,256 @@
+domain: homicidal_ideation
+priority: 93
+
+lexical_signals:
+  high:
+    phrases:
+      - "want to hurt someone"
+      - "going to kill them"
+      - "homicidal thoughts"
+      - "planning to harm someone"
+      - "want to attack someone"
+      - "going to hurt them"
+      - "thinking about hurting someone"
+      - "thinking about hurting my"
+      - "thoughts about hurting someone"
+      - "want to kill"
+      # --- caregiver reports phrases ---
+      - "he said he wants to hurt"
+      - "she said she wants to hurt"
+      - "he threatened to hurt"
+      - "she threatened to hurt"
+      - "he's been threatening"
+      - "she's been threatening"
+      - "my son said he wants to hurt"
+      - "my husband said he wants to hurt"
+      - "my brother said he wants to hurt"
+      - "he's talking about hurting"
+      - "she's talking about hurting"
+      # --- weapon fixation phrases ---
+      - "keeps looking at knives"
+      - "researching guns"
+      - "looking at the gun"
+      - "staring at the knife"
+      - "keeps going to the drawer"
+      - "looking up weapons"
+      - "went to the gun case"
+      - "keeps checking the closet"
+      # --- specific targets phrases ---
+      - "knows where they live"
+      - "knows where he lives"
+      - "knows where she lives"
+      - "following them"
+      - "been following him"
+      - "been following her"
+      - "tracked them down"
+      - "found their address"
+      - "waiting outside their"
+      # --- escalating language phrases ---
+      - "about to snap"
+      - "going to do something"
+      - "gonna do something I can't take back"
+      - "about to lose it"
+      - "going to explode"
+      - "can't hold back anymore"
+      - "running out of patience"
+    regex:
+      - "(want|going|plan|think|thought)\\s+(to|about|of)\\s+(hurt|kill|harm|attack|stab|shoot|strangle)"
+      - "\\b(hurt|kill|harm|attack)\\b.{0,15}\\b(someone|them|him|her|people)\\b"
+      - "(homicid|want.{0,5}(to\\s+)?kill)"
+      - "thinking\\s+about\\s+(hurting|killing|harming|attacking)"
+      - "thoughts?\\s+(about|of)\\s+(hurting|killing|harming)"
+      # --- euphemistic/fragmented violence ---
+      - "(about|of)\\s+harming\\s+(someone|him|her|them|my|a person)"
+      - "(smash|bash|crack|crush).{0,15}(head|skull|face)"
+      - "(make|stop).{0,10}(him|her|them)\\s+(stop|shut|not)\\s+(breath|living|exist)"
+      - "shut\\s+(him|her|them)\\s+up\\s+(for\\s+good|permanently|forever)"
+      - "doing\\s+something\\s+to\\s+(shut|stop|end|silence|get rid)"
+      - "picture\\s+(hurting|hitting|killing|stabbing|choking)"
+      # --- caregiver reports regex ---
+      - "(he|she|my\\s+(son|daughter|husband|wife|brother|sister|nephew|uncle|father|mother))\\s+(said|says|told|keeps\\s+saying|been\\s+saying|mentioned|admitted).{0,30}(want|wants|going|gonna|threatened?).{0,20}(to\\s+)?(hurt|kill|harm|attack)"
+      - "(he|she|they)'?(s|ve)?\\s+(been\\s+)?(threatening|talking\\s+about\\s+hurt|talking\\s+about\\s+kill|making\\s+threats)"
+      - "(my\\s+)?(son|daughter|husband|wife|brother|sister|nephew|uncle|father|mother).{0,30}(threatening|wants?\\s+to\\s+(hurt|kill|harm))"
+      # --- weapon fixation regex ---
+      - "(keep|keeps|kept|been)\\s+(looking|staring|going|checking).{0,15}(at\\s+)?(the\\s+)?(knife|knives|gun|weapon|drawer|closet|cabinet|lockbox)"
+      - "(research|look|search)\\w*\\s+(up|for|into).{0,15}(gun|weapon|knife|firearm|ammunition)"
+      - "(went|goes|going)\\s+(to|for|toward|into)\\s+(the\\s+)?(gun|weapon|knife).{0,10}(case|drawer|cabinet|closet|safe)"
+      - "(staring|looking|glancing)\\s+at\\s+(the\\s+)?(knife|gun|weapon|bat|hammer|tool)"
+      # --- specific targets regex ---
+      - "(know|knows|found|got|has).{0,15}(where|their|his|her).{0,10}(live|address|house|apartment|work)"
+      - "(follow|following|followed|tracking|stalking|watching).{0,15}(them|him|her|the\\s+(neighbor|coworker|boss|ex))"
+      - "(wait|waiting|waited)\\s+(outside|near|for|by).{0,20}(their|his|her|the)"
+      - "(found|looked\\s+up|tracked).{0,15}(address|where|location|house)"
+      # --- escalating language regex ---
+      - "(about\\s+to|going\\s+to|gonna|might)\\s+(snap|explode|lose\\s+it|do\\s+something|blow)"
+      - "(can'?t|won'?t)\\s+(hold|control|stop).{0,15}(back|myself|anymore|any\\s+longer)"
+      - "(running|ran)\\s+out\\s+of\\s+(patience|control|restraint)"
+      - "(losing|lost)\\s+(my\\s+)?(grip|control|patience|mind)"
+      - "do\\s+something\\s+(I|that).{0,20}(regret|can'?t\\s+take\\s+back|irreversible)"
+  medium:
+    phrases:
+      - "feel like I could hurt someone"
+      - "violent thoughts"
+      - "want to harm others"
+      - "losing control of anger"
+      - "I keep seeing his face and I get this heat"
+      - "intrusive angry thoughts"
+      - "can't stop thinking about violence"
+      - "fantasizing about hurting"
+      - "want to beat them up"
+      - "snap at someone"
+      - "terrified I'll do something irreversible"
+      - "scared I'll do something I can't take back"
+      - "worried I'll snap"
+      - "thoughts about getting what he deserves"
+      - "thoughts about getting what she deserves"
+      - "I keep looking at the drawer"
+      # --- euphemistic / conditional / third-person ---
+      - "about to snap"
+      - "runs scenarios in my head"
+      - "pressure valve is about to blow"
+      - "showing them"
+      - "make them pay"
+      - "teach them a lesson"
+      - "getting darker"
+      - "they deserve what's coming"
+      - "someone needs to pay"
+      - "know where they live"
+      - "been following them"
+      - "been watching them"
+      - "I keep picturing it"
+      - "can't get the image out of my head"
+      - "the thoughts won't stop"
+      - "I see red when I think about"
+      - "hands shake when I think about"
+      # --- from missed scenarios analysis ---
+      - "harming someone specific"
+      - "worried about my control"
+      - "I picture hurting him"
+      - "I could smash his head"
+      - "make him stop breathing"
+      - "got scared of myself"
+      - "scared I'm gonna mess up and somebody's gonna get hurt"
+      - "I might swing without thinking"
+      - "thought about specific ways"
+      - "various scenarios"
+      - "chemical compounds and their effects"
+      - "looking up things online"
+      - "looking up weapons"
+      - "drew disturbing pictures"
+      - "he said he wanted to hurt"
+      - "she said she wanted to hurt"
+      - "think about going over there"
+      - "think about hitting him"
+      - "think about hitting her"
+      - "intrusive thoughts"
+      # --- Phase 4: expanded patterns for missed scenarios ---
+      - "thinking about what if they weren't around"
+      - "looking up where they live"
+      - "thoughts getting darker"
+      - "more detailed thoughts"
+      - "can't stop thinking about hurting"
+    regex:
+      - "(hurt|kill|harm|attack).{0,15}(my|that|this)"
+      - "(violen|aggressi).{0,20}(thought|urge|impuls|fantasi)"
+      - "(losing|lost)\\s+control.{0,15}(anger|rage|temper)"
+      - "(snap|explode|blow up|lash out).{0,20}(at|on)\\s+(someone|them|him|her|people)"
+      - "(thought|think|plan).{0,20}(wait|follow|find|confront).{0,20}(him|her|them|coworker|boss|neighbor)"
+      - "(handgun|gun|weapon|knife|firearm).{0,30}(lockbox|drawer|cabinet|closet|car|keep|looking|think)"
+      # --- from missed scenarios analysis ---
+      - "(bad|scary|dark|disturbing|concerning)\\s+(thoughts?|ones?)\\s+(about|lately|regarding)"
+      - "(picture|imagine|visualize|see)\\s+(myself\\s+)?(hurting|hitting|choking|stabbing|killing|punching)"
+      - "(swing|hit|punch|attack)\\s+(without\\s+thinking|on\\s+impulse|before\\s+I)"
+      - "(scared|afraid|worried|terrified)\\s+(of\\s+)?(myself|what I might|I'll|I might)"
+      - "doing\\s+something\\s+to\\s+(him|her|them|my|someone)"
+      - "(I\\s+)?think\\s+about\\s+(hitting|hurting|harming|going after|going over)"
+      - "(thoughts|thinking).{0,20}(getting\\s+more|more\\s+frequent|more\\s+detailed|more\\s+intense|won't\\s+stop)"
+      - "(box\\s+cutter|hammer|metal\\s+pipe|baseball\\s+bat|bat).{0,30}(work|tool|truck|just|it's)"
+      - "(he|she)\\s+said.{0,15}(wanted?\\s+to\\s+)?(hurt|harm|kill)"
+      - "(do|did)\\s+something.{0,15}(irreversible|can't take back|regret|terrible|stupid)"
+      - "(terrified|scared|worried|afraid).{0,20}(snap|hurt|do something|lose control|go off)"
+      # --- euphemistic intent ---
+      - "(fantasiz|dream|think)\\w*\\s+(about|of)\\s+(hurt|harm|kill|attack|get)"
+      # --- conditional threat ---
+      - "(about to|going to|might)\\s+(snap|explode|lose it|do something)"
+      # --- weapon fixation ---
+      - "(stared at|looking at|keep looking at)\\s+(the |a )?(knife|gun|weapon|drawer|bat)"
+      # --- third-person caregiver report ---
+      - "(he|she|they|my)\\s+(keeps?|been)\\s+(talking about|saying|threatening)"
+      # --- making them pay / deserve ---
+      - "(make|teach|show)\\s+(them|him|her)\\s+(a lesson|what|pay)"
+      - "(deserve|coming to)\\s+(them|him|her|what)"
+      # --- Phase 4: expanded patterns for missed scenarios ---
+      - "(think|thinking).{0,40}(what|what if).{0,30}(weren't|gone|wasn't).{0,40}(around|here|alive)"
+      - "(looked up|looking up|found).{0,30}(where|address).{0,30}(he|she|they|lives?)"
+      - "(getting|more|thoughts).{0,15}(darker|intense|detailed|specific|frequent)"
+      - "(thought|thinking).{0,30}(specific|detailed).{0,20}(way|how|plan)"
+      # --- caregiver interrupted disclosure ---
+      - "(said|saying).{0,20}(wanted?\\s+to|thing about).{0,30}(hurt|harm)"
+      # --- weapons + visual/research ---
+      - "(looking\\s+up|research).{0,15}(weapon|knife|gun).{0,30}(drew|picture|sketch)"
+  low:
+    partials:
+      - "violent urges"
+      - "homicidal"
+      - "rage"
+      - "hurt someone"
+      - "kill someone"
+      - "dark thoughts about"
+      - "intense feelings toward"
+      - "can't stop thinking about them"
+      - "revenge"
+      - "snap"
+      - "lose it"
+
+negation_handling:
+  patterns:
+    - "don't want to hurt anyone"
+    - "not violent"
+    - "no intent to harm"
+    # --- financial/logistics/non-violent context ---
+    - "hurt my budget"
+    - "hurt my routine"
+    - "hurt my schedule"
+    - "harm my routine"
+    - "harm my schedule"
+    - "coverage"
+    - "storage"
+    - "encourage"
+    - "discourage"
+    - "insurance coverage"
+    - "drug coverage"
+    - "copay"
+    - "out of pocket"
+    - "might hurt my"
+    - "could hurt my"
+    - "this hurts my"
+    - "won't kill me"
+    - "it's killing me"
+    - "killing my back"
+    - "killing my budget"
+    # --- pharmacy / substring false-positive context (handled by \b in regex) ---
+    # --- medical pain/appetite context ---
+    - "hurts my appetite"
+    - "kills my appetite"
+    - "hurts to eat"
+    - "hurts to swallow"
+    - "hurts my mouth"
+    - "hurts my throat"
+    - "hurts my stomach"
+    - "hurt the wound"
+    - "hurt the stitches"
+    - "hurt the incision"
+    - "don't want to hurt"
+    - "killing my appetite"
+    - "hurts when I"
+    - "it hurts to"
+    # --- administrative / routine context suppression ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "when can I come in"
+    - "medication refill"
+    - "need a refill"
+    - "routine check"
+    - "just a question"
+    - "appointment timing"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/medication/flows/adverse_reaction.yaml b/decision/taxonomy/medication/flows/adverse_reaction.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a4c35f091584699a400c446ddd1b555e38f6e836
--- /dev/null
+++ b/decision/taxonomy/medication/flows/adverse_reaction.yaml
@@ -0,0 +1,36 @@
+flow_id: adverse_reaction
+type: escalation
+domain: medication
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: adverse_reaction_urgent
+      goal: "Acknowledge the reaction and transfer to clinical staff immediately"
+      tone: calm_urgent
+      must_include:
+        - "nurse"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "stop taking"
+        - "diagnos"
+        - "don't worry"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: adverse_reaction_handoff
+      goal: "Transfer to nurse with adverse reaction context"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/medication/flows/clarify.yaml b/decision/taxonomy/medication/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b5284d84a2a5ec0ee7e4768b940384a4ab048ae5
--- /dev/null
+++ b/decision/taxonomy/medication/flows/clarify.yaml
@@ -0,0 +1,24 @@
+flow_id: clarify
+type: clarification
+domain: medication
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: medication_clarify
+      goal: "Ask patient to clarify their medication-related concern"
+      tone: gentle_professional
+      must_include:
+        - "medication"
+      must_ask:
+        - "help me understand"
+      must_not:
+        - "diagnos"
+      max_questions: 2
+    collects:
+      - medication_concern_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/medication/flows/refill_request.yaml b/decision/taxonomy/medication/flows/refill_request.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ffd1c44c2cd5b206a16cdcae87788bc0875fbcaf
--- /dev/null
+++ b/decision/taxonomy/medication/flows/refill_request.yaml
@@ -0,0 +1,43 @@
+flow_id: refill_request
+type: service
+domain: medication
+
+required_slots:
+  - medication_name
+  - pharmacy_preference
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: refill_gather
+      goal: "Gather medication name and pharmacy for refill"
+      tone: helpful_professional
+      must_include:
+        - "medication"
+        - "refill"
+      must_ask:
+        - "which medication"
+        - "pharmacy"
+      must_not:
+        - "diagnos"
+      max_questions: 2
+    collects:
+      - medication_name
+      - pharmacy_preference
+
+  - step: 2
+    type: respond
+    response_spec:
+      id: refill_confirm
+      goal: "Confirm refill request has been submitted"
+      tone: warm_professional
+      must_include:
+        - "refill"
+        - "submitted"
+      must_ask: []
+      must_not: []
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/medication/flows/side_effects.yaml b/decision/taxonomy/medication/flows/side_effects.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6a387cc0b792fa7cf8b70c12e26e90d559a8f48c
--- /dev/null
+++ b/decision/taxonomy/medication/flows/side_effects.yaml
@@ -0,0 +1,33 @@
+flow_id: side_effects
+type: assessment
+domain: medication
+
+required_slots:
+  - medication_name
+  - side_effect_description
+  - side_effect_severity
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: side_effect_gather
+      goal: "Understand which medication and what side effects the patient is experiencing"
+      tone: empathetic_professional
+      must_include:
+        - "medication"
+        - "experiencing"
+      must_ask:
+        - "which medication"
+        - "describe the side effect"
+      must_not:
+        - "stop taking"
+        - "diagnos"
+      max_questions: 2
+    collects:
+      - medication_name
+      - side_effect_description
+
+exit:
+  on_complete: end
+  on_unclear: clarify
diff --git a/decision/taxonomy/medication/rules.yaml b/decision/taxonomy/medication/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..070dc855dca10f2e5c27d36c15339f8d35bc86f0
--- /dev/null
+++ b/decision/taxonomy/medication/rules.yaml
@@ -0,0 +1,36 @@
+domain: medication
+
+decision_rules:
+  - id: medication_adverse_reaction
+    if:
+      confidence: high
+      slots_present:
+        - adverse_reaction
+    then:
+      flow: adverse_reaction
+
+  - id: medication_side_effects
+    if:
+      confidence: high
+      slots_present:
+        - side_effect_report
+    then:
+      flow: side_effects
+
+  - id: medication_refill_high
+    if:
+      confidence: high
+    then:
+      flow: refill_request
+
+  - id: medication_refill_medium
+    if:
+      confidence: medium
+    then:
+      flow: refill_request
+
+  - id: medication_low
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/medication/triggers.yaml b/decision/taxonomy/medication/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ca26c0e29654a6ea469dc2e624878d07479139ae
--- /dev/null
+++ b/decision/taxonomy/medication/triggers.yaml
@@ -0,0 +1,66 @@
+domain: medication
+priority: 50
+
+lexical_signals:
+  high:
+    phrases:
+      - "medication refill"
+      - "need a refill"
+      - "ran out of medication"
+      - "side effect"
+      - "adverse reaction"
+      - "allergic reaction to medication"
+    regex:
+      - "(need|want|request)\\s+(a\\s+)?refill"
+      - "side\\s+effect"
+  medium:
+    phrases:
+      - "my prescription"
+      - "my medicine"
+      - "pills"
+      - "feeling sick from medication"
+    partials:
+      - "dosage"
+      - "pharmacy"
+  low:
+    phrases:
+      - "something I'm taking"
+    partials:
+      - "tablet"
+      - "capsule"
+
+negation_handling:
+  patterns:
+    - "no medication issues"
+    - "medications are fine"
+    # --- Phase 5: R1 false escalation reduction ---
+    # Dosage / timing questions
+    - "when should I take"
+    - "what time do I take"
+    - "how many pills"
+    - "instructions say"
+    - "how often do I take"
+    - "with food or without"
+    # Side effect inquiry (not adverse reaction)
+    - "is this a side effect"
+    - "could this be from my medication"
+    - "normal side effect"
+    - "my usual side effect"
+    - "same thing happened before"
+    - "already aware"
+    - "expected side effect"
+    - "common side effect"
+    # Routine / administrative context
+    - "routine medication question"
+    - "medication review"
+    - "checking on my"
+    - "just a question about my medication"
+    - "medication list"
+    - "my pharmacy"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/medication_nonadherence/flows/clarify.yaml b/decision/taxonomy/medication_nonadherence/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9d8073ff06aa40f901c59ae4326b5cc9a93675bb
--- /dev/null
+++ b/decision/taxonomy/medication_nonadherence/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: medication_nonadherence
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: medication_nonadherence_clarify
+      goal: "Ask patient to describe their medication nonadherence symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - medication_nonadherence_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/medication_nonadherence/flows/escalate_r1.yaml b/decision/taxonomy/medication_nonadherence/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..2608cbd3e4b009bc99b6003c133c08ed936379f7
--- /dev/null
+++ b/decision/taxonomy/medication_nonadherence/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: medication_nonadherence
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/medication_nonadherence/flows/handoff.yaml b/decision/taxonomy/medication_nonadherence/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..548b724124286f90509529c65203211cc6889d3f
--- /dev/null
+++ b/decision/taxonomy/medication_nonadherence/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: medication_nonadherence
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: medication_nonadherence_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: medication_nonadherence_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/medication_nonadherence/rules.yaml b/decision/taxonomy/medication_nonadherence/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8fa784f589143ba2beb0e238f99d09413c691ef2
--- /dev/null
+++ b/decision/taxonomy/medication_nonadherence/rules.yaml
@@ -0,0 +1,21 @@
+domain: medication_nonadherence
+target_risk_class: R1
+
+decision_rules:
+  - id: medication_nonadherence_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r1
+
+  - id: medication_nonadherence_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r1
+
+  - id: medication_nonadherence_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/medication_nonadherence/triggers.yaml b/decision/taxonomy/medication_nonadherence/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3a8ce05eda21663c917fa2335460a13e5dc903bf
--- /dev/null
+++ b/decision/taxonomy/medication_nonadherence/triggers.yaml
@@ -0,0 +1,34 @@
+domain: medication_nonadherence
+priority: 49
+
+lexical_signals:
+  high:
+    phrases:
+      - "stopped taking my medication"
+      - "not taking prescribed medicines"
+      - "decided to quit my medications"
+      - "medication non-adherence"
+      - "refusing to take pills"
+      - "haven't taken medication in days"
+    regex:
+      - "(stopped|quit|not)\\s+tak(ing|e)\\s+(my\\s+)?medic"
+  medium:
+    phrases:
+      - "been skipping doses"
+      - "forgot medication a few times"
+      - "not sure about my medications"
+      - "taking less than prescribed"
+      - "ran out and didn't refill"
+      - "missed several doses"
+  low:
+    partials:
+      - "missed dose"
+      - "medication question"
+      - "skipping pills"
+
+negation_handling:
+  patterns:
+    - "taking all medications"
+    - "medication adherence is good"
+    - "taking as prescribed"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/meningitis_signal/flows/clarify.yaml b/decision/taxonomy/meningitis_signal/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..98f804e964b91b4978e0b1a2dde81844fe2bd90b
--- /dev/null
+++ b/decision/taxonomy/meningitis_signal/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: meningitis_signal
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: meningitis_signal_clarify
+      goal: "Ask patient to describe their meningitis signal symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - meningitis_signal_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/meningitis_signal/flows/escalate_r2.yaml b/decision/taxonomy/meningitis_signal/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..70867542df0bc2885fd669cefe7bc915e7192060
--- /dev/null
+++ b/decision/taxonomy/meningitis_signal/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: meningitis_signal
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/meningitis_signal/flows/handoff.yaml b/decision/taxonomy/meningitis_signal/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7a9dcaf1c6fb7baeedb0d74299c7b3975e0e26d8
--- /dev/null
+++ b/decision/taxonomy/meningitis_signal/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: meningitis_signal
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: meningitis_signal_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: meningitis_signal_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/meningitis_signal/flows/safety_screen.yaml b/decision/taxonomy/meningitis_signal/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..67544f3fd2234a2fa77e703523ad7b3f178a5e97
--- /dev/null
+++ b/decision/taxonomy/meningitis_signal/flows/safety_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: safety_screen
+type: screening
+domain: meningitis_signal
+
+required_slots:
+  - headache_severity
+  - fever_temperature
+  - neck_stiffness
+  - photophobia
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "headache severity"
+        - "fever temperature"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - headache_severity
+      - fever_temperature
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "neck stiffness"
+        - "photophobia"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - neck_stiffness
+      - photophobia
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/decision/taxonomy/meningitis_signal/rules.yaml b/decision/taxonomy/meningitis_signal/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d4b1fb8c986fccca1b6f3b4c6a1a46eac049c088
--- /dev/null
+++ b/decision/taxonomy/meningitis_signal/rules.yaml
@@ -0,0 +1,33 @@
+domain: meningitis_signal
+target_risk_class: R3
+
+decision_rules:
+  - id: meningitis_signal_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: meningitis_signal_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: meningitis_signal_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: meningitis_signal_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: meningitis_signal_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/meningitis_signal/triggers.yaml b/decision/taxonomy/meningitis_signal/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..bd0848680e70b806537524122af5f1319c67ecbf
--- /dev/null
+++ b/decision/taxonomy/meningitis_signal/triggers.yaml
@@ -0,0 +1,185 @@
+domain: meningitis_signal
+priority: 73
+
+lexical_signals:
+  high:
+    phrases:
+      # --- original ---
+      - "severe headache with fever and stiff neck"
+      - "meningitis symptoms"
+      - "worst headache with high fever"
+      - "neck is stiff and have fever"
+      - "headache fever and can't bend neck"
+      # --- expanded naturalistic ---
+      - "stiff neck and high fever"
+      - "worst headache of my life with fever"
+      - "can't bend my neck forward and have fever"
+      - "neck stiffness with headache and fever"
+      - "light hurts my eyes and I have a fever"
+      - "rash that doesn't blanch with fever"
+      - "petechial rash with headache"
+      - "terrible headache and my neck won't move"
+      - "fever and my neck is so stiff I can't look down"
+      - "splitting headache with stiff neck and temperature"
+      - "high fever and headache and neck pain"
+      - "purple rash with fever and headache"
+      - "rash that doesn't go away when pressed with fever"
+      - "child has fever and stiff neck and headache"
+      - "baby has bulging fontanelle and fever"
+      - "confusion with fever and stiff neck"
+      - "headache so bad with fever and neck won't bend"
+      - "sensitivity to light with fever and neck stiffness"
+      - "vomiting with headache and stiff neck"
+    regex:
+      # --- original ---
+      - "(headache|neck\\s+stiff).*(fever)"
+      - "(meningitis|meningeal)"
+      # --- expanded ---
+      - "(stiff|rigid)\\s+neck\\s+(and|with)\\s+(high\\s+)?fever"
+      - "worst\\s+headache.*(fever|temperature|temp)"
+      - "can'?t\\s+(bend|move|turn)\\s+(my\\s+)?neck.*(fever|temperature)"
+      - "fever.*(stiff|rigid)\\s+neck"
+      - "fever.*(can'?t\\s+(bend|move|turn))\\s+(my\\s+)?neck"
+      - "(light|bright)\\s+(hurts|bothers|sensitivity).*(fever)"
+      - "(rash|petechiae|purpura)\\s+(that\\s+)?(doesn'?t|does\\s+not|won'?t)\\s+(blanch|fade|go\\s+away).*(fever)"
+      - "(petechial|purpuric|non-blanching)\\s+rash.*(headache|fever)"
+      - "(headache|neck).*(headache|neck).*(fever|temperature)"
+      - "(fever|temperature).*(headache).*(stiff|rigid|neck)"
+      - "(confusion|confused|altered).*(fever).*(neck|headache)"
+      - "(vomiting|nausea).*(headache).*(stiff\\s+neck|neck\\s+stiff)"
+  medium:
+    phrases:
+      # --- original ---
+      - "bad headache and fever"
+      - "stiff neck with headache"
+      - "headache and high temperature"
+      - "neck stiffness and fever"
+      - "photophobia with headache and fever"
+      - "headache with neck pain and fever"
+      # --- expanded naturalistic ---
+      - "severe headache with fever"
+      - "neck pain and can't look down"
+      - "high fever and confused"
+      - "rash spreading with fever"
+      - "headache with stiff neck"
+      - "neck is really stiff and I have a headache"
+      - "headache and neck ache together"
+      - "fever with really bad headache"
+      - "light sensitivity with headache"
+      - "my neck hurts to bend forward"
+      - "fever and a terrible headache"
+      - "throbbing headache with neck stiffness"
+      - "headache and can't tolerate light"
+      - "nauseous with headache and stiff neck"
+      - "neck pain with fever and headache"
+      - "high temperature and very bad headache"
+      - "headache is getting worse with neck pain"
+      - "neck so sore can't look down"
+      - "new rash with fever"
+      - "spots on skin with headache"
+      - "headache and very sensitive to light"
+      - "fever and intense head pain"
+      - "headache and neck won't turn"
+      - "stiff neck since this morning with headache"
+      - "confused with high temperature"
+      - "sleepy and hard to wake with fever"
+      - "irritable with fever and headache"
+      - "rash appeared with a fever"
+      # --- MINIMIZER coverage ---
+      - "just a bad headache and my neck is a bit stiff"
+      - "headache and I feel kind of warm"
+      - "neck is sort of stiff and I have a headache"
+      - "probably just a cold but I have a headache and my neck hurts"
+      - "I've had worse headaches before"
+      - "light is kind of annoying"
+      - "headache isn't that bad, just won't go away"
+      - "felt kind of warm and my head hurts"
+      - "stiff neck and headache but probably just tension"
+      - "head hurts and the light really bothers me"
+      - "neck is a bit sore and I have a headache"
+      - "headache keeps coming back and I feel warm"
+    regex:
+      - "(severe|terrible|bad|awful|intense|worst)\\s+headache\\s+(with|and)\\s+(a\\s+)?(fever|temperature)"
+      - "neck\\s+(pain|ache|stiff|sore)\\s+(with|and)\\s+headache"
+      - "(stiff|rigid|sore)\\s+neck\\s+(with|and)\\s+(a\\s+)?headache"
+      - "(high\\s+)?(fever|temperature)\\s+(and|with)\\s+(confused|confusion|altered)"
+      - "(light|photo)\\s*(phobia|sensitiv).*(headache|head\\s+pain)"
+      - "headache\\s+(and|with)\\s+(can'?t\\s+tolerate|sensitive\\s+to)\\s+light"
+      - "rash\\s+(spread|appear|develop|new).*(fever|temperature)"
+      - "(spots|rash|marks)\\s+(on\\s+)?(skin|body).*(headache|fever)"
+      - "(nauseous|vomiting|nausea)\\s+(with|and)\\s+(headache|stiff\\s+neck)"
+      - "(sleepy|drowsy|lethargic|hard\\s+to\\s+wake).*(fever)"
+      - "(irritable|fussy)\\s+(with|and)\\s+(fever|headache|temperature)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(headache|head\\s+hurts?).{0,25}(neck).{0,15}(a\\s+)?(bit|little|kind of|sort of|stiff|sore|tight)"
+      - "(neck).{0,15}(stiff|sore|tight|hurts).{0,20}(headache|head\\s+hurts|head\\s+is)"
+      - "(headache|head).{0,20}(warm|fever|temperature|feverish).{0,15}(kind of|a bit|little|sort of|feel)"
+      - "(just|only).{0,10}(a\\s+)?(bad|nasty|persistent|annoying).{0,10}(headache|head).{0,20}(neck|stiff|warm|fever)"
+      - "(light|bright|lights?).{0,15}(bother|annoy|hurt|sensitive|can'?t stand).{0,20}(headache|head|fever|warm)"
+      - "(headache).{0,25}(won'?t|doesn'?t|not).{0,10}(go away|let up|quit|stop|ease|improve)"
+      - "(probably|might be).{0,10}(just|nothing|cold|flu|tension|stress).{0,20}(headache|neck|stiff|fever|warm)"
+    partials:
+      - "photophobia with headache"
+      - "neck stiffness"
+      - "headache and fever"
+      - "fever and rash"
+      - "non-blanching rash"
+  low:
+    partials:
+      # --- original ---
+      - "meningitis"
+      - "stiff neck headache"
+      - "nuchal rigidity"
+      # --- expanded ---
+      - "meningeal signs"
+      - "meningeal irritation"
+      - "photophobia"
+      - "kernig sign"
+      - "brudzinski sign"
+      - "lumbar puncture"
+      - "CSF analysis"
+      - "bacterial meningitis"
+      - "viral meningitis"
+      - "aseptic meningitis"
+      - "meningococcal"
+      - "meningococcemia"
+      - "petechiae"
+      - "purpura"
+      - "encephalitis"
+      - "neck rigidity"
+      - "jolt accentuation"
+      - "febrile neck stiffness"
+
+negation_handling:
+  patterns:
+    # --- original ---
+    - "no neck stiffness"
+    - "headache resolved"
+    - "no meningitis signs"
+    # --- expanded ---
+    - "neck stiffness from sleeping wrong"
+    - "tension headache"
+    - "migraine without fever"
+    - "neck strain"
+    - "stiff neck from bad pillow"
+    - "headache but no fever"
+    - "neck pain from arthritis"
+    - "cervical spondylosis causing neck stiffness"
+    - "no fever with headache"
+    - "rash blanches with pressure"
+    - "meningitis ruled out"
+    - "lumbar puncture was normal"
+    - "CSF was clear"
+    - "no meningeal signs"
+    - "headache improving"
+    - "neck stiffness resolving"
+    - "viral illness with headache only"
+    - "muscle tension in neck"
+    - "no photophobia"
+    - "no rash present"
+    - "torticollis causing neck stiffness"
+    - "neck stiff from whiplash"
+    - "afebrile with headache"
+    - "febrile but no neck stiffness"
+    - "headache from sinus congestion"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/missed_followup/flows/clarify.yaml b/decision/taxonomy/missed_followup/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f9d0bdcc628a9cecdd64c0cf0c77d725c792ef30
--- /dev/null
+++ b/decision/taxonomy/missed_followup/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: missed_followup
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: missed_followup_clarify
+      goal: "Ask patient to describe their missed followup symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - missed_followup_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/missed_followup/flows/escalate_r1.yaml b/decision/taxonomy/missed_followup/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7601a059b3c13139e7de4c1875a5eb835b819d2e
--- /dev/null
+++ b/decision/taxonomy/missed_followup/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: missed_followup
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/missed_followup/flows/handoff.yaml b/decision/taxonomy/missed_followup/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3b193a681462dafa78cbe579eb20b121b9cfc5e6
--- /dev/null
+++ b/decision/taxonomy/missed_followup/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: missed_followup
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: missed_followup_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: missed_followup_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/missed_followup/rules.yaml b/decision/taxonomy/missed_followup/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..66800ee94d904f28c8feda2f9e6ff6d83ef31ebb
--- /dev/null
+++ b/decision/taxonomy/missed_followup/rules.yaml
@@ -0,0 +1,21 @@
+domain: missed_followup
+target_risk_class: R1
+
+decision_rules:
+  - id: missed_followup_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r1
+
+  - id: missed_followup_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r1
+
+  - id: missed_followup_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/missed_followup/triggers.yaml b/decision/taxonomy/missed_followup/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0b8c5b557022e0b17cb3427a41c8de15e8ca1dfb
--- /dev/null
+++ b/decision/taxonomy/missed_followup/triggers.yaml
@@ -0,0 +1,77 @@
+domain: missed_followup
+priority: 48
+
+lexical_signals:
+  high:
+    phrases:
+      - "missed my doctor appointment"
+      - "missed my follow-up appointment"
+      - "couldn't make it to my appointment"
+      - "missed post-surgery checkup"
+      - "skipped my follow-up visit"
+      - "didn't go to my scheduled appointment"
+      - "no-showed my appointment"
+      - "never went to my follow-up"
+      - "didn't make it to the doctor"
+      - "haven't seen the doctor since discharge"
+      - "didn't follow up with my doctor"
+      - "I was supposed to see the doctor but didn't"
+      - "haven't gone back to the doctor"
+    regex:
+      - "miss(ed)?\\s+(my\\s+)?(follow.?up|appointment|checkup|doctor)"
+      - "(didn'?t|never|haven'?t)\\s+(go|gone|been|went|make it)\\s+(to\\s+)?(my\\s+)?(follow.?up|appointment|doctor|checkup)"
+      - "(skip|skipped)\\s+(my\\s+)?(follow.?up|appointment|visit)"
+  medium:
+    phrases:
+      - "need to reschedule follow-up"
+      - "can't make my appointment"
+      - "haven't scheduled follow-up yet"
+      - "going to miss my appointment"
+      - "forgot to schedule follow-up"
+      - "don't have a follow-up scheduled"
+      - "no one told me about a follow-up"
+      - "wasn't sure when to follow up"
+      - "haven't called to schedule"
+      - "don't know when my follow-up is"
+      - "haven't made an appointment yet"
+  low:
+    partials:
+      - "missed appointment"
+      - "follow-up"
+      - "reschedule"
+      - "no appointment"
+      - "haven't scheduled"
+
+negation_handling:
+  patterns:
+    - "went to my appointment"
+    - "follow-up completed"
+    - "appointment kept"
+    # --- active scheduling / wound care context ---
+    - "schedule a follow-up"
+    - "scheduling a follow-up"
+    - "need to schedule a follow-up"
+    - "schedule my follow-up"
+    - "scheduling my follow-up"
+    - "when is my follow-up"
+    - "when's my follow-up"
+    - "follow-up is listed"
+    - "follow-up on"
+    - "my follow-up is"
+    - "follow-up appointment"
+    - "wound care"
+    - "dressing change"
+    - "bandage change"
+    - "stitches"
+    - "wound check"
+    - "might need to reschedule"
+    - "need to reschedule"
+    - "trying to avoid rescheduling"
+    - "want to reschedule"
+    - "reschedule my"
+    - "scheduling"
+    - "schedule an appointment"
+    - "make an appointment"
+    - "need to schedule"
+    - "book an appointment"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/new_jaundice/flows/clarify.yaml b/decision/taxonomy/new_jaundice/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ba5e04f817e72ad56d7bb66743a7971df13caf3e
--- /dev/null
+++ b/decision/taxonomy/new_jaundice/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: new_jaundice
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: new_jaundice_clarify
+      goal: "Ask patient to describe their new jaundice symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - new_jaundice_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/new_jaundice/flows/escalate_r2.yaml b/decision/taxonomy/new_jaundice/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f3c8d1438dafd5445e38d44202591b22e3a72f24
--- /dev/null
+++ b/decision/taxonomy/new_jaundice/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: new_jaundice
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/new_jaundice/flows/handoff.yaml b/decision/taxonomy/new_jaundice/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..053bb46367eff2df52b0e5bd88d819e00521462e
--- /dev/null
+++ b/decision/taxonomy/new_jaundice/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: new_jaundice
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: new_jaundice_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: new_jaundice_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/new_jaundice/flows/safety_screen.yaml b/decision/taxonomy/new_jaundice/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6a2c798308318c4873957032866ab9491f9899c0
--- /dev/null
+++ b/decision/taxonomy/new_jaundice/flows/safety_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: safety_screen
+type: screening
+domain: new_jaundice
+
+required_slots:
+  - jaundice_onset
+  - stool_color
+  - urine_color
+  - abdominal_pain
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "jaundice onset"
+        - "stool color"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - jaundice_onset
+      - stool_color
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "urine color"
+        - "abdominal pain"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - urine_color
+      - abdominal_pain
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/decision/taxonomy/new_jaundice/rules.yaml b/decision/taxonomy/new_jaundice/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d7f62b64d268dc9bac9097258a7eb879b33b1a9a
--- /dev/null
+++ b/decision/taxonomy/new_jaundice/rules.yaml
@@ -0,0 +1,27 @@
+domain: new_jaundice
+target_risk_class: R2
+
+decision_rules:
+  - id: new_jaundice_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: new_jaundice_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: new_jaundice_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: new_jaundice_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/new_jaundice/triggers.yaml b/decision/taxonomy/new_jaundice/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..829c216c94bc5b16f9758050126f3aac6ea84e50
--- /dev/null
+++ b/decision/taxonomy/new_jaundice/triggers.yaml
@@ -0,0 +1,181 @@
+domain: new_jaundice
+priority: 67
+
+lexical_signals:
+  high:
+    phrases:
+      - "skin turned yellow"
+      - "eyes are yellow"
+      - "new jaundice"
+      - "suddenly jaundiced"
+      - "skin and eyes turning yellow"
+      - "yellow discoloration of skin"
+      - "eyes look kind of yellow"
+      - "eyes look yellow"
+      - "my skin has a yellowish tint"
+      - "whites of my eyes are yellow"
+      - "I look jaundiced"
+      - "someone told me I look yellow"
+      - "my face and eyes turned yellow"
+      - "yellow skin and dark urine"
+      - "eyes are definitely yellow not white"
+      - "skin is yellow and I am itching all over"
+      - "whole body has a yellow tone"
+      - "sclera are yellow"
+      - "jaundiced appearance"
+      - "my baby looks yellow"
+      - "newborn is turning yellow"
+      - "skin yellowing and pale stools"
+      - "dark brown urine and yellow eyes"
+    regex:
+      - "(skin|eyes?)\\s+(turn|are|look|looked?)\\s+(kind\\s+of\\s+)?yellow"
+      - "(new|sudden)\\s+jaundice"
+      - "(stool|poop|bowel).*(light|pale|clay|beige|gray|grey|putty|white)"
+      - "eyes?\\s+(look|looked|seem)\\s+(kinda?|kind\\s+of|sort\\s+of\\s+)?yellow"
+      - "poop\\s+looked?\\s+(really\\s+)?light.*clay"
+      - "stools?\\s+(have\\s+)?been\\s+(weirdly\\s+)?light"
+      - "whites?\\s+(of\\s+)?(my\\s+)?eyes?.*(yellow|gold)"
+      - "sclera.*(yellow|icter)"
+      - "(skin|face|body).*(yellow|jaundic).*(tint|tone|hue|color)"
+      - "(yellow|jaundic).*(skin|face|body|eyes?).*(dark|brown|tea|cola)\\s+(urine|pee)"
+      - "(baby|newborn|infant).*(yellow|jaundic)"
+      - "(yellow|jaundic).*(itch|scratch|pruritus)"
+      - "(someone|wife|husband|friend|coworker|family)\\s+(said|told|noticed).*(yellow|jaundic)"
+      - "whole\\s+body.*(yellow|jaundic)"
+      - "(urine|pee).*(dark|brown|tea|cola).*(eyes?|skin).*(yellow|jaundic)"
+  medium:
+    phrases:
+      - "noticed yellow skin"
+      - "eyes look yellowish"
+      - "skin seems yellow"
+      - "jaundice appearing"
+      - "yellowing of skin or eyes"
+      - "scleral icterus"
+      - "eyes look off"
+      - "pee looks darker"
+      - "urine is dark"
+      - "light-colored stool"
+      - "clay-colored stool"
+      - "eyes looked off"
+      - "belly feels sore under my ribs"
+      - "upper belly pain"
+      - "right side of my upper belly"
+      - "my urine is the color of tea"
+      - "poop has been really pale lately"
+      - "stool is almost white"
+      - "I have been itching everywhere"
+      - "skin is itchy all over for no reason"
+      - "urine looks like dark beer"
+      - "my pee is brown"
+      - "stool floats and is pale"
+      - "color of my skin looks off to me"
+      - "something wrong with the color of my eyes"
+      - "I noticed my skin looks different in the mirror"
+      - "under my tongue looks yellow"
+      - "palms of my hands look yellow"
+      - "itching worse at night"
+      - "belly pain right upper area with yellow skin"
+      - "nauseous and my eyes look yellow"
+      - "lost my appetite and skin looks yellow"
+      - "my wife said I look like a banana"
+    regex:
+      - "eyes?\\s+(look|looked|seem)\\s+(off|tired|weird|strange|different)"
+      - "(pee|urine)\\s+(look|is|seem)s?\\s+(dark|brown|tea|cola)"
+      - "(stool|poop).*(pale|light|weird|clay|gray|grey|putty|beige)"
+      - "(belly|abdomen|side).*(sore|ache|pain|hurt).*rib"
+      - "(sister|brother|wife|husband|partner|coworker|friend)\\s+said\\s+my\\s+eyes"
+      - "can't\\s+unsee\\s+it"
+      - "(mirror|bathroom).*(yellow|off)"
+      - "something.*(off|wrong).*mirror"
+      - "what\\s+I'm\\s+seeing\\s+in\\s+.*mirror"
+      - "don't\\s+like\\s+what.*seeing\\s+in\\s+.*mirror"
+      - "looked?\\s+.?yellow"
+      - "i\\s+look\\s+.?off"
+      - "(look|looking)\\s+(off|yellow|jaundic)"
+      - "ache.*(right\\s+side|under\\s+(the\\s+)?ribs?)"
+      - "(right\\s+side|under\\s+(the\\s+)?ribs?).*(ache|sore|pain|hurt)"
+      - "(coworker|friend|partner).*said.*look.*(off|yellow|weird)"
+      - "look.*(off|yellow|weird).*(lighting|mirror|bathroom)"
+      - "(urine|pee).*(color|colour).*(tea|beer|cola|brown|dark|amber)"
+      - "(stool|poop).*(float|almost\\s+white|chalky)"
+      - "(itch|scratch|pruritus).*(everywhere|all\\s+over|whole\\s+body|no\\s+reason)"
+      - "(nausea|nauseous|appetite|weight).*(yellow|jaundic)"
+      - "(yellow|jaundic).*(nausea|nauseous|appetite|weight)"
+      - "(palm|hand|tongue|gum).*(yellow|jaundic)"
+      - "itch.*(worse|bad).*(night|evening|bed)"
+      - "(belly|abdomen).*(pain|ache|sore).*(yellow|jaundic)"
+      - "(banana|golden|orange).*(skin|color|look)"
+      # --- additional caregiver observation ---
+      - "(noticed|saw|see)\\s+(his|her|my|the)\\s+(skin|eyes|face).{0,15}(yellow|jaundic|different|off)"
+      - "(skin|eyes).{0,15}(look|looks|looking)\\s+(more\\s+)?(yellow|golden|jaundiced)"
+  low:
+    partials:
+      - "jaundice"
+      - "yellow skin"
+      - "icterus"
+      - "yellowing"
+      - "yellow eyes"
+      - "dark urine"
+      - "pale stool"
+      - "clay stool"
+      - "eyes look off"
+      - "skin color off"
+      - "tea colored urine"
+      - "brown urine"
+      - "light poop"
+      - "itching all over"
+      - "yellowish"
+      - "skin tint"
+      - "eyes different"
+      - "pale bowel"
+      - "scleral icterus"
+      - "bilirubin"
+
+negation_handling:
+  patterns:
+    - "no jaundice"
+    - "skin color normal"
+    - "yellowness resolved"
+    - "eyes look normal"
+    - "stool color normal"
+    - "not jaundiced"
+    - "no yellow discoloration"
+    - "eyes are white and clear"
+    - "skin is not yellow"
+    - "urine color is normal"
+    - "stool is normal brown"
+    - "no yellowing of eyes"
+    - "jaundice has resolved"
+    - "bilirubin is normal"
+    - "no itching"
+    - "skin color back to normal"
+    - "eyes cleared up"
+    - "yellow tint went away"
+    - "complexion looks normal"
+    - "no scleral icterus"
+    - "jaundice improving"
+    - "urine is light colored again"
+    - "stool color returned to normal"
+    # --- wound drainage context (R1 wound_concern scenarios) ---
+    - "drainage from wound"
+    - "wound drainage"
+    - "drainage on the bandage"
+    - "drainage on the gauze"
+    - "drainage on the pad"
+    - "yellowish drainage from"
+    - "clear yellow fluid"
+    - "incision drainage"
+    - "wound is draining"
+    - "bandage has drainage"
+    - "wound care"
+    - "dressing change"
+    - "stitches"
+    - "sutures"
+    - "staples"
+    # --- urine color context (R1 post_procedure_incontinence) ---
+    - "urine leakage"
+    - "leaking urine"
+    - "incontinence"
+    - "bladder control"
+    - "urine on pad"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/npo_violation/flows/clarify.yaml b/decision/taxonomy/npo_violation/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..94e3a270403c7bd0400a4ff4eecf1b857cae7da1
--- /dev/null
+++ b/decision/taxonomy/npo_violation/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: npo_violation
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: npo_clarify
+      goal: "Ask patient to describe their eating or drinking concern before surgery"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - npo_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/npo_violation/flows/escalate_r2.yaml b/decision/taxonomy/npo_violation/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..02cddf63930f11d16b9f59a7c4afbb54c13b0b97
--- /dev/null
+++ b/decision/taxonomy/npo_violation/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: npo_violation
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: npo_r2_escalation_notice
+      goal: "Inform patient that the surgical team will follow up same day about their intake before the procedure"
+      tone: calm_reassuring
+      must_include:
+        - "surgical team"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: surgical_nurse
+    urgency: same_day
+    response_spec:
+      id: npo_r2_handoff
+      goal: "Schedule same-day surgical team callback with NPO violation context"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/npo_violation/flows/escalate_r3.yaml b/decision/taxonomy/npo_violation/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0ffe96a247bdd48cdbbe142d60534f1ec729cf2c
--- /dev/null
+++ b/decision/taxonomy/npo_violation/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: npo_violation
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Instruct patient to call 911 immediately and inform them of nurse transfer"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/npo_violation/flows/reassure_low_risk.yaml b/decision/taxonomy/npo_violation/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ccf3e6acfc4de512c86c2e726ec2ff5ea2c58130
--- /dev/null
+++ b/decision/taxonomy/npo_violation/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: npo_violation
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: npo_reassure
+      goal: "Acknowledge the patient followed their fasting instructions correctly and note their care team will be informed"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/npo_violation/flows/safety_screen.yaml b/decision/taxonomy/npo_violation/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..775dd54d7cd94dfc770659685b5126a10ee74512
--- /dev/null
+++ b/decision/taxonomy/npo_violation/flows/safety_screen.yaml
@@ -0,0 +1,52 @@
+flow_id: safety_screen
+type: screening
+domain: npo_violation
+
+required_slots:
+  - npo_last_intake_time
+  - npo_intake_type
+  - surgery_scheduled_time
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: npo_screen_step1
+      goal: "Determine what the patient consumed and when"
+      tone: calm_urgent
+      must_include:
+        - "eating"
+      must_ask:
+        - "What did you eat or drink?"
+        - "When was the last time you had anything to eat or drink?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - npo_last_intake_time
+      - npo_intake_type
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: npo_screen_step2
+      goal: "Confirm the scheduled surgery time to assess the NPO window"
+      tone: calm_urgent
+      must_include:
+        - "surgery"
+      must_ask:
+        - "What time is your surgery or procedure scheduled?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 1
+    collects:
+      - surgery_scheduled_time
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_r3: escalate_r3
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_r2
diff --git a/decision/taxonomy/npo_violation/rules.yaml b/decision/taxonomy/npo_violation/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..cff629ca5fe883fb31d23ce1057c8b139be8b15a
--- /dev/null
+++ b/decision/taxonomy/npo_violation/rules.yaml
@@ -0,0 +1,33 @@
+domain: npo_violation
+target_risk_class: R2
+
+decision_rules:
+  - id: npo_violation_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: npo_violation_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: npo_violation_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: npo_violation_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: npo_violation_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/npo_violation/triggers.yaml b/decision/taxonomy/npo_violation/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..72bd5b63c14f9271fed31208c44e0dac971064f9
--- /dev/null
+++ b/decision/taxonomy/npo_violation/triggers.yaml
@@ -0,0 +1,76 @@
+domain: npo_violation
+priority: 70
+
+lexical_signals:
+  high:
+    phrases:
+      - "had breakfast this morning"
+      - "ate before surgery"
+      - "drank coffee before my procedure"
+      - "had food this morning"
+      - "I ate something"
+      - "had a meal before"
+      - "drank water this morning"
+      - "ate a snack before coming in"
+      - "had juice this morning"
+      - "I just ate"
+      - "had toast and coffee"
+      - "ate lunch before my surgery"
+      - "drank milk this morning"
+      - "had some cereal before coming"
+      - "ate right before coming to the hospital"
+      - "I had eggs this morning"
+      - "chewed some gum this morning"
+      - "drank tea before my procedure"
+    regex:
+      - "(ate|eaten|had|drank|drink|consumed|swallowed).{0,20}(this\\s+morning|before\\s+(surgery|procedure|operation)|before\\s+com)"
+      - "(breakfast|lunch|meal|food|snack|coffee|juice|tea|water|milk).{0,20}(this\\s+morning|before\\s+(surgery|procedure|operation)|today)"
+      - "(this\\s+morning|today).{0,20}(ate|eaten|had|drank|drink|consumed).{0,15}(breakfast|food|meal|snack|coffee)"
+      - "(?<!haven't )(?<!didn't )(?<!not )(ate|eaten|had\\s+food|had\\s+breakfast|had\\s+a\\s+meal).{0,15}(before|prior|today|this\\s+morning)"
+      - "(just|already).{0,10}(ate|eaten|had).{0,15}(food|breakfast|meal|snack|something)"
+      - "(food|drink|coffee|water|juice|tea|milk).{0,15}(before|prior).{0,10}(surgery|procedure|operation|anesthesia)"
+  medium:
+    phrases:
+      - "when was I supposed to stop eating"
+      - "can I eat"
+      - "NPO instructions"
+      - "fasting instructions"
+      - "nothing by mouth question"
+      - "when should I stop eating"
+      - "how long before surgery no food"
+      - "can I drink water before surgery"
+      - "eating and drinking before procedure"
+      - "fasting for surgery"
+      - "not sure about the fasting rules"
+      - "confused about when to stop eating"
+  low:
+    partials:
+      - "fasting"
+      - "empty stomach"
+      - "nothing by mouth"
+      - "NPO"
+      - "stop eating"
+
+negation_handling:
+  patterns:
+    - "haven't eaten"
+    - "nothing to eat"
+    - "fasted since midnight"
+    - "empty stomach"
+    - "no food or drink"
+    - "followed the fasting instructions"
+    - "haven't had anything to eat"
+    - "haven't had anything to drink"
+    - "no food since midnight"
+    - "no water since midnight"
+    - "I fasted"
+    - "nothing by mouth"
+    - "didn't eat anything"
+    - "didn't drink anything"
+    - "stopped eating last night"
+    - "last meal was last night"
+    - "no breakfast this morning"
+    - "skipped breakfast"
+    - "followed NPO instructions"
+    - "stomach is empty"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/overdose/flows/clarify.yaml b/decision/taxonomy/overdose/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ffeac412a4148eb1bcf30970c637aacb6b3cd06b
--- /dev/null
+++ b/decision/taxonomy/overdose/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: overdose
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: overdose_clarify
+      goal: "Ask patient to describe their overdose symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - overdose_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/overdose/flows/escalate_r3.yaml b/decision/taxonomy/overdose/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..64683b8abd5cddae4d93a17ccf179dde9ec9a8fb
--- /dev/null
+++ b/decision/taxonomy/overdose/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: overdose
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Inform patient this requires immediate clinical attention and they will be transferred"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/overdose/flows/handoff.yaml b/decision/taxonomy/overdose/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..922ed1ae11f4d1f40ab10b4809c3b9283818d329
--- /dev/null
+++ b/decision/taxonomy/overdose/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: overdose
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: overdose_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: overdose_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/overdose/flows/reassure_low_risk.yaml b/decision/taxonomy/overdose/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ec4b9483625b7b371816189ea6de20abf6c02975
--- /dev/null
+++ b/decision/taxonomy/overdose/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: overdose
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: overdose_reassure
+      goal: "Acknowledge the patient's concern about medication, note that their care team will be informed for routine follow-up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/overdose/flows/safety_screen.yaml b/decision/taxonomy/overdose/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ac6887ee65f0a0bb771a3e92568baac1a146627c
--- /dev/null
+++ b/decision/taxonomy/overdose/flows/safety_screen.yaml
@@ -0,0 +1,54 @@
+flow_id: safety_screen
+type: screening
+domain: overdose
+
+required_slots:
+  - substance_taken
+  - amount_timing
+  - intent
+  - consciousness_level
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: overdose_screen_step1
+      goal: "Determine what substance was taken and when"
+      tone: calm_urgent
+      must_include:
+        - "medication"
+      must_ask:
+        - "Can you tell me what you took or what substance is involved?"
+        - "How much did you take and when?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - substance_taken
+      - amount_timing
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: overdose_screen_step2
+      goal: "Screen for intentionality and current mental status"
+      tone: calm_urgent
+      must_include:
+        - "understand"
+      must_ask:
+        - "Was this accidental, like a mix-up with your medications?"
+        - "How are you feeling right now — are you alert and thinking clearly?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - intent
+      - consciousness_level
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_r3
diff --git a/decision/taxonomy/overdose/rules.yaml b/decision/taxonomy/overdose/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9b5d544c42aec478dbcf904f193f5061df3037db
--- /dev/null
+++ b/decision/taxonomy/overdose/rules.yaml
@@ -0,0 +1,27 @@
+domain: overdose
+target_risk_class: R3
+
+decision_rules:
+  - id: overdose_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: overdose_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: overdose_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: overdose_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
diff --git a/decision/taxonomy/overdose/triggers.yaml b/decision/taxonomy/overdose/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7d82e9c769b13ca30e1be8f664d30e58e4ff25ac
--- /dev/null
+++ b/decision/taxonomy/overdose/triggers.yaml
@@ -0,0 +1,155 @@
+domain: overdose
+priority: 91
+
+lexical_signals:
+  high:
+    phrases:
+      - "took too many pills"
+      - "overdosed"
+      - "took too much medication"
+      - "drug overdose"
+      - "swallowed a bottle of pills"
+      - "poisoning"
+      - "intentional overdose"
+      - "took a handful of pills"
+      - "took way too many"
+    regex:
+      - "(took|swallowed|ate|ingested)\\s+(too\\s+many|a\\s+bottle|a\\s+handful|way\\s+too)"
+      - "overdos"
+      - "(took|swallowed).{0,20}(pills|medication|meds|tablets).{0,20}(too many|bunch|handful|all)"
+      - "(too many|too much).{0,15}(pills|medication|meds|tablets|dose)"
+      - "(took|taken|swallowed)\\s+more\\s+(pills|meds|medication|tablets).{0,20}than"
+  medium:
+    phrases:
+      - "accidentally took extra dose"
+      - "took wrong medication"
+      - "double dosed accidentally"
+      - "ingested something toxic"
+      - "took someone else's medication"
+      - "mixed up my pills"
+      - "taken too much of my"
+      - "might have taken too much"
+      - "took more than I should have"
+      - "my head feels floaty"
+      - "can't think straight after taking"
+      - "grabbed the wrong bottle"
+      - "took some pills and now I'm foggy"
+      - "took pills and feel weird"
+      # --- vague quantity / euphemistic ---
+      - "took a bunch"
+      - "took more than usual"
+      - "kept taking them"
+      - "shut my brain off"
+      - "wanted to sleep"
+      - "grabbed everything"
+      - "empty bottles"
+      - "found empty"
+      - "stared at the pill bottle"
+      - "looking at my medications"
+      - "counting my pills"
+      - "took them all"
+      - "finished the bottle"
+      - "drank with my pills"
+      - "washed them down with alcohol"
+    regex:
+      - "(took|taken|swallowed).{0,20}(too much|extra|wrong|more than)"
+      - "(pills|medication|meds).{0,20}(mixed\\s+up|wrong\\s+(one|pill|med|bottle)|too\\s+many|too\\s+much)"
+      - "(floaty|woozy|drowsy|sleepy|foggy|fuzzy).{0,30}(pills|medication|meds|took)"
+      - "(pills|medication|meds|took).{0,30}(floaty|woozy|drowsy|sleepy|foggy|fuzzy)"
+      - "(took|taken|grabbed).{0,20}(wrong\\s+bottle|wrong\\s+pills|wrong\\s+meds)"
+      - "(might|may)\\s+have\\s+(taken|swallowed).{0,20}(\\d+|several|multiple|few|bunch)"
+      - "took\\s+(some\\s+)?pills.{0,30}(foggy|fuzzy|weird|off|dizzy|sleepy|drowsy|heart)"
+      - "(pills|meds|medication).{0,30}(beer|alcohol|drink|wine|liquor)"
+      # --- vague quantity ---
+      - "(took|swallowed|ate|ingested)\\s+(a\\s+)?(bunch|handful|lots?|several|all)\\s+(of\\s+)?(my\\s+)?(pills|meds|medication|tablets)"
+      # --- substance mixing ---
+      - "(pills?|meds?|medication)\\s+(with|and)\\s+(wine|beer|drink|alcohol|vodka|whiskey)"
+      # --- wine/alcohol + medication combination ---
+      - "(wine|drink|alcohol).{0,30}(medication|meds|pills|double|twice)"
+      # --- uncertain disclosure ---
+      - "(think|maybe|might have)\\s+(took|taken)\\s+(too many|extra|more)"
+      # --- minimizer qualification (downplaying severity) ---
+      - "(took|taken|took some).{0,20}(pills|meds).{0,30}(usual|normally|nothing serious)"
+      # --- intent signals ---
+      - "(wanted|trying)\\s+to\\s+(sleep|not wake|shut|numb|stop feeling)"
+      - "(empty|finished|drank)\\s+(the\\s+)?(bottle|pills|meds|medication)"
+      # --- accidental double-dosing / caregiver report ---
+      - "(took|taken|may have taken).{0,15}(twice|them twice|double|two doses|his meds twice|her meds twice)"
+      - "pill\\s+organizer.{0,15}(empty|was empty|gone)"
+      - "(re-?dosed|re-?dose|dosed\\s+(himself|herself|again|twice))"
+      - "(nodding|nods)\\s+off"
+      - "(breathing|breaths?).{0,15}(slow|shallow|barely|labored|weak|faint)"
+      - "(slur|slurring|slurred).{0,15}(speech|words|mid-?sentence|off)"
+      - "(can'?t|couldn'?t)\\s+(stay\\s+awake|keep\\s+(his|her|my)\\s+eyes)"
+      - "(drifts?|drift(s|ed|ing))\\s+(off|away|in and out)"
+      # --- pediatric ingestion ---
+      - "(child|baby|toddler|kid|grandbaby|grandson|granddaughter).{0,30}(got into|ate|swallowed|took|found)"
+      - "(got|gotten)\\s+into\\s+(something|my|the|his|her).{0,15}(pills|meds|medication|medicine|bottle)"
+      - "pill\\s+bottle\\s+(on|was on|found on)\\s+(the\\s+)?floor"
+      - "(pills?|bottle).{0,15}(missing|gone|empty|almost empty|only a few left|less than)"
+      - "(found|saw|noticed).{0,15}(empty|open|spilled).{0,15}(pill|med|bottle|container)"
+  low:
+    partials:
+      - "too much"
+      - "wrong medicine"
+      - "extra pill"
+      - "toxic"
+      - "took too many"
+      - "overdose"
+      - "wrong bottle"
+      - "confused about my pills"
+      - "mixed up my medications"
+
+negation_handling:
+  patterns:
+    - "didn't take too much"
+    - "no overdose"
+    - "took correct dose"
+    - "took the right amount"
+    - "taking as prescribed"
+    - "following the directions"
+    - "confused about the schedule"
+    - "confused about the timing"
+    - "confused about which pill"
+    - "confused about the instructions"
+    - "mixed up the times"
+    - "not sure when to take"
+    - "forgot which one"
+    - "haven't taken too many"
+    - "took my regular dose"
+    - "just the prescribed amount"
+    # --- R1 medication question/inquiry context (suppress) ---
+    - "medication question"
+    - "asking about medication"
+    - "asking about my medication"
+    - "confused about my medication"
+    - "question about my pills"
+    - "question about my meds"
+    - "new prescription"
+    - "new medication"
+    - "just started this medication"
+    - "side effect question"
+    - "is this a side effect"
+    - "could this be a side effect"
+    - "normal side effect"
+    - "expected side effect"
+    - "refill request"
+    - "pharmacy question"
+    - "need a refill"
+    - "prescription refill"
+    - "medication refill"
+    - "how should I take"
+    - "when should I take"
+    - "what time should I take"
+    - "instructions for my medication"
+    - "dosing question"
+    - "dosing schedule"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+    - "medication review"
+    - "med check"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/palpitations_dizziness/flows/clarify.yaml b/decision/taxonomy/palpitations_dizziness/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d29a17dafd3f6daa9433031b4d2c90fb34160e25
--- /dev/null
+++ b/decision/taxonomy/palpitations_dizziness/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: palpitations_dizziness
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: palpitations_dizziness_clarify
+      goal: "Ask patient to describe their palpitations dizziness symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - palpitations_dizziness_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/palpitations_dizziness/flows/escalate_r2.yaml b/decision/taxonomy/palpitations_dizziness/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6ace437c61ec9af780a469499345d3cf8fc04c9e
--- /dev/null
+++ b/decision/taxonomy/palpitations_dizziness/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: palpitations_dizziness
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/palpitations_dizziness/flows/handoff.yaml b/decision/taxonomy/palpitations_dizziness/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..39841b7eabfc35ab40e6e2cc972b08e250935515
--- /dev/null
+++ b/decision/taxonomy/palpitations_dizziness/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: palpitations_dizziness
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: palpitations_dizziness_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: palpitations_dizziness_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/palpitations_dizziness/flows/safety_screen.yaml b/decision/taxonomy/palpitations_dizziness/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e1e0d19e3b024f900773d9f535c40f149bfe64b3
--- /dev/null
+++ b/decision/taxonomy/palpitations_dizziness/flows/safety_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: safety_screen
+type: screening
+domain: palpitations_dizziness
+
+required_slots:
+  - palpitation_frequency
+  - dizziness_severity
+  - syncope_history
+  - episode_duration
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "palpitation frequency"
+        - "dizziness severity"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - palpitation_frequency
+      - dizziness_severity
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "syncope history"
+        - "episode duration"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - syncope_history
+      - episode_duration
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/decision/taxonomy/palpitations_dizziness/rules.yaml b/decision/taxonomy/palpitations_dizziness/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..03cbc1a6057f2732784ba8d9b87bba68171496be
--- /dev/null
+++ b/decision/taxonomy/palpitations_dizziness/rules.yaml
@@ -0,0 +1,27 @@
+domain: palpitations_dizziness
+target_risk_class: R2
+
+decision_rules:
+  - id: palpitations_dizziness_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: palpitations_dizziness_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: palpitations_dizziness_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: palpitations_dizziness_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/palpitations_dizziness/triggers.yaml b/decision/taxonomy/palpitations_dizziness/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..89d96ada515c0e11cc465be188712c8f36cc96e4
--- /dev/null
+++ b/decision/taxonomy/palpitations_dizziness/triggers.yaml
@@ -0,0 +1,192 @@
+domain: palpitations_dizziness
+priority: 75
+
+lexical_signals:
+  high:
+    phrases:
+      # --- ORIGINAL ---
+      - "heart racing and dizzy"
+      - "palpitations with lightheadedness"
+      - "heart pounding and almost fainted"
+      - "irregular heartbeat and dizzy"
+      - "heart fluttering and feel faint"
+      # --- EXPANDED naturalistic ---
+      - "heart is racing and I feel dizzy"
+      - "heart is pounding and I feel like I'm going to faint"
+      - "heart skipping beats and I'm lightheaded"
+      - "heart won't slow down and I feel faint"
+      - "fluttering in my chest and I'm dizzy"
+      - "heart going really fast and the room is spinning"
+      - "dizzy and my heart is pounding out of my chest"
+      - "heart is racing out of nowhere and I can't stand up"
+      - "irregular heartbeat and I almost passed out"
+      - "heart is beating so fast and I'm about to pass out"
+      - "heart is skipping and I feel like I'm going to fall"
+      - "palpitations and almost blacked out"
+      - "heart feels like it's going to explode and I'm dizzy"
+      - "woke up with my heart racing and the room spinning"
+      - "heart rate is really high and I feel unsteady"
+    regex:
+      # --- ORIGINAL ---
+      - "(heart|palpitation).*(dizz|faint|lightheaded)"
+      - "(palpitat|racing).*(dizz|faint)"
+      # --- EXPANDED ---
+      - "heart.{0,15}(racing|pounding|fast|rapid|beating\\s+(so\\s+)?fast).{0,30}(dizz|faint|lightheaded|unsteady|spin|pass\\s+out|black\\s+out)"
+      - "(dizz|faint|lightheaded|unsteady|spin|room\\s+spin).{0,30}heart.{0,15}(racing|pounding|fast|rapid|beating)"
+      - "heart.{0,10}(skip|flutter|irregular|erratic).{0,30}(dizz|faint|lightheaded|unsteady|fall)"
+      - "(skip|flutter|irregular|erratic).{0,10}heart.{0,30}(dizz|faint|lightheaded)"
+      - "heart.{0,10}won'?t\\s+slow\\s+down.{0,20}(dizz|faint|lightheaded|unsteady)"
+      - "(palpitat|racing|pounding).{0,30}(almost|nearly|about\\s+to)\\s+(passed?\\s+out|faint|black)"
+      - "heart.{0,10}(going\\s+to\\s+explode|out\\s+of\\s+(my\\s+)?chest).{0,20}(dizz|faint|lightheaded)"
+      - "woke\\s+up.{0,20}heart\\s+(racing|pounding|fast).{0,20}(dizz|spin|faint)"
+  medium:
+    phrases:
+      # --- ORIGINAL ---
+      - "heart feels like it's racing"
+      - "palpitations and feel faint"
+      - "irregular heartbeat with dizziness"
+      - "heart skipping and lightheaded"
+      - "heart fluttering and unsteady"
+      # --- EXPANDED naturalistic ---
+      - "heart is racing"
+      - "heart is pounding"
+      - "heart skipping beats"
+      - "fluttering in my chest"
+      - "heart won't slow down"
+      - "irregular heartbeat"
+      - "heart going really fast"
+      - "heart beating out of my chest"
+      - "my pulse is really high"
+      - "heart is doing something weird"
+      - "heart feels like it's flipping"
+      - "heart keeps stopping and starting"
+      - "can feel my heart beating really hard"
+      - "my heart won't stop racing"
+      - "heart is going crazy"
+      - "heartbeat feels irregular"
+      - "heart pounding when I'm just sitting"
+      - "random heart racing"
+      - "heart beats really fast then slows down"
+      - "heart rate is really high"
+      - "feel my heart beating in my ears"
+      - "thumping in my chest"
+      - "pounding in my chest"
+      - "heart jumping around"
+      - "I can hear my heartbeat in my ears"
+      - "dizzy and heart racing"
+      - "heart is pounding and I don't feel right"
+      # --- MINIMIZER coverage ---
+      - "heart does this sometimes, no big deal"
+      - "just felt a little off"
+      - "probably just caffeine"
+      - "heart flutters"
+      - "just little skips"
+      - "heart feels funny sometimes"
+      - "a bit lightheaded but probably nothing"
+      - "probably just anxiety"
+      - "heart races sometimes but it passes"
+      # --- additional patterns ---
+      - "heart does this weird thing where it stops"
+      - "feel my pulse in my throat"
+      - "heart goes really fast for no reason"
+    regex:
+      # --- EXPANDED ---
+      - "heart\\s+(is\\s+)?(racing|pounding|beating\\s+(really\\s+)?fast|going\\s+(really\\s+)?fast|hammering|thumping)"
+      - "heart\\s+(is\\s+)?(skipping|fluttering|flipping|jumping|doing\\s+something\\s+weird)"
+      - "heart\\s+(keeps?|won'?t\\s+stop)\\s+(racing|pounding|skipping|beating\\s+fast)"
+      - "(flutter|skip|thump|pound|jump|race).{0,10}(in\\s+)?(my\\s+)?chest"
+      - "heart.{0,10}(out\\s+of|beating\\s+out)\\s+(my\\s+)?chest"
+      - "(can|I)\\s+(feel|hear)\\s+(my\\s+)?heart\\s*(beat|pound|thump|race)"
+      - "heart\\s+(beat|rate|rhythm).{0,10}(irregular|erratic|abnormal|weird|off|fast|high|rapid)"
+      - "(pulse|heart\\s+rate)\\s+(is\\s+)?(really\\s+)?(high|fast|elevated|rapid|\\d{3})"
+      - "heart.{0,10}(going|went)\\s+crazy"
+      - "heart.{0,15}(stop|start).{0,10}(and\\s+)?(start|stop)"
+      - "heart.{0,10}(beats?|goes?)\\s+(really\\s+)?fast\\s+(then|and)\\s+(slow|stop|normal)"
+      - "(random|sudden|out\\s+of\\s+nowhere)\\s+(heart\\s+)?rac(ing|e)"
+      - "heart\\s+(pound|rac|thump).{0,15}(just\\s+)?(sit|rest|lying|lay|stand|still|doing\\s+nothing)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(just|only).{0,10}(a\\s+)?(little|bit|slight).{0,10}(flutter|skip|race|palpit|lightheaded|dizzy|faint)"
+      - "(heart|chest).{0,15}(funny|weird|off|flutter|skip|noticeable).{0,15}(sometimes|occasionally|now and then|kind of|sort of)"
+      - "(probably|might be).{0,10}(just|nothing|caffeine|stress|anxiety|normal).{0,20}(heart|palpit|dizzy|lightheaded|flutter)"
+      - "(lightheaded|dizzy|faint).{0,15}(a\\s+)?(bit|little|kind of|sort of|comes and goes)"
+      # --- Intermittent + vague patterns (R2 recall) ---
+      - "(racing|palpitations|flutter).{0,40}(intermittent|comes and goes|on and off).{0,40}(hard to|can't|difficult).{0,15}(pin down|describe|explain)"
+      - "(heart|pulse).{0,15}(intermittent|sporadic|random).{0,20}(racing|fast|pounding|flutter)"
+      - "(comes and goes|on and off|intermittent).{0,25}(heart|racing|palpitations|flutter)"
+      # --- Caregiver concern patterns ---
+      - "(worried|concerned|noticed).{0,15}(his|her|their|my).{0,10}(heart|pulse).{0,15}(racing|fast|pounding|irregular)"
+      - "(his|her|their).{0,10}(heart).{0,15}(racing|pounding|fast).{0,15}(episodes?|spells?|attacks?)"
+      - "(he|she|they).{0,10}(seems?|looks?|appears?).{0,15}(lightheaded|dizzy|unsteady|faint)"
+      - "(worried|concerned|scared).{0,20}(about|because).{0,15}(heart|palpitations|racing|dizziness)"
+    partials:
+      - "heart going fast"
+      - "heart beating fast"
+      - "heart thumping"
+      - "heart hammering"
+      - "heart doing something weird"
+      - "chest fluttering"
+      - "pulse high"
+  low:
+    partials:
+      # --- ORIGINAL ---
+      - "palpitations"
+      - "heart racing"
+      - "fluttering heart"
+      # --- EXPANDED ---
+      - "heart pounding"
+      - "heart skipping"
+      - "heart fluttering"
+      - "irregular heartbeat"
+      - "rapid heartbeat"
+      - "fast heart rate"
+      - "tachycardia"
+      - "arrhythmia"
+      - "atrial fibrillation"
+      - "afib"
+      - "a-fib"
+      - "heart rhythm"
+      - "heart rate high"
+      - "pulse fast"
+      - "pulse racing"
+      - "skipped beats"
+      - "extra beats"
+      - "PVCs"
+      - "PACs"
+
+negation_handling:
+  patterns:
+    # --- ORIGINAL ---
+    - "no palpitations"
+    - "heart rhythm is fine"
+    - "no dizziness with heart"
+    # --- EXPANDED ---
+    - "no heart racing"
+    - "heart rate is normal"
+    - "heart rate is fine"
+    - "heart rhythm is normal"
+    - "heartbeat is regular"
+    - "heartbeat is normal"
+    - "palpitations stopped"
+    - "palpitations resolved"
+    - "palpitations went away"
+    - "heart not racing anymore"
+    - "heart has calmed down"
+    - "heart slowed down"
+    - "heart is back to normal"
+    - "heart rate came back down"
+    - "no more skipping"
+    - "no more fluttering"
+    - "no irregular heartbeat"
+    - "palpitations much better"
+    - "heart feels fine now"
+    - "heart feels normal"
+    - "pulse is normal"
+    - "no racing heart"
+    - "dizziness gone and heart is fine"
+    - "only when I exercise"
+    - "only with caffeine"
+    - "only after coffee"
+    - "only when I'm anxious"
+    - "goes away when I rest"
+    - "resolved on its own"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/persistent_dizziness/flows/clarify.yaml b/decision/taxonomy/persistent_dizziness/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..53989bb586b5b1d12fbb080478da116f0b92f73b
--- /dev/null
+++ b/decision/taxonomy/persistent_dizziness/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: persistent_dizziness
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: persistent_dizziness_clarify
+      goal: "Ask patient to describe their persistent dizziness symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - persistent_dizziness_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/persistent_dizziness/flows/escalate_r1.yaml b/decision/taxonomy/persistent_dizziness/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..96a700d6a865c96bb39f80e038da82521bb4d18b
--- /dev/null
+++ b/decision/taxonomy/persistent_dizziness/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: persistent_dizziness
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/persistent_dizziness/flows/handoff.yaml b/decision/taxonomy/persistent_dizziness/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..15bb1562177187286b9ef4ce01930c32ed66e2c0
--- /dev/null
+++ b/decision/taxonomy/persistent_dizziness/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: persistent_dizziness
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: persistent_dizziness_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: persistent_dizziness_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/persistent_dizziness/rules.yaml b/decision/taxonomy/persistent_dizziness/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c9b89fd7c9fdacbfb62fc8a39fa4f95f9136e053
--- /dev/null
+++ b/decision/taxonomy/persistent_dizziness/rules.yaml
@@ -0,0 +1,21 @@
+domain: persistent_dizziness
+target_risk_class: R1
+
+decision_rules:
+  - id: persistent_dizziness_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r1
+
+  - id: persistent_dizziness_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r1
+
+  - id: persistent_dizziness_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/persistent_dizziness/triggers.yaml b/decision/taxonomy/persistent_dizziness/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1916de22be5a90d5287361cb2ddf9b4bf0cba0f2
--- /dev/null
+++ b/decision/taxonomy/persistent_dizziness/triggers.yaml
@@ -0,0 +1,52 @@
+domain: persistent_dizziness
+priority: 43
+
+lexical_signals:
+  high:
+    phrases:
+      - "dizzy all the time"
+      - "constant dizziness"
+      - "vertigo won't go away"
+      - "persistent dizziness for days"
+      - "room keeps spinning"
+      - "dizzy every time I stand up"
+      - "dizziness hasn't stopped"
+      - "the dizziness won't go away"
+      - "been dizzy for days"
+      - "dizzy since I got home"
+      - "still dizzy"
+      - "always lightheaded"
+      - "world is spinning"
+    regex:
+      - "(constant|persistent|chronic|continuous|ongoing)\\s+(dizziness|vertigo)"
+      - "dizzy\\s+(all\\s+the\\s+time|every|since|for\\s+days|since\\s+discharge|won'?t)"
+      - "(room|world)\\s+(keeps?|is|won'?t\\s+stop)\\s+spin"
+      - "(still|always|keeps?)\\s+(dizzy|lightheaded)"
+  medium:
+    phrases:
+      - "been feeling dizzy frequently"
+      - "dizziness comes and goes"
+      - "lightheaded frequently"
+      - "vertigo episodes recurring"
+      - "balance has been off"
+      - "feeling unsteady"
+      - "keep getting dizzy"
+      - "head is spinning"
+      - "everything spins when I stand"
+      - "dizzy when I move"
+      - "lightheaded when I get up"
+  low:
+    partials:
+      - "dizzy"
+      - "dizziness"
+      - "vertigo"
+      - "lightheaded"
+      - "unsteady"
+      - "off-balance"
+
+negation_handling:
+  patterns:
+    - "not dizzy"
+    - "dizziness resolved"
+    - "balance is fine"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/persistent_vomiting/flows/clarify.yaml b/decision/taxonomy/persistent_vomiting/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..06f9005139ce8ec3f5712f89b52a2c115f06e8e2
--- /dev/null
+++ b/decision/taxonomy/persistent_vomiting/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: persistent_vomiting
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: persistent_vomiting_clarify
+      goal: "Ask patient to describe their persistent vomiting symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - persistent_vomiting_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/persistent_vomiting/flows/escalate_r2.yaml b/decision/taxonomy/persistent_vomiting/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d9495e0c4ca51248471c797405bb27eeedcfd1db
--- /dev/null
+++ b/decision/taxonomy/persistent_vomiting/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: persistent_vomiting
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/persistent_vomiting/flows/handoff.yaml b/decision/taxonomy/persistent_vomiting/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..bc5cb39986371952514ada07a8ee229b48bd4902
--- /dev/null
+++ b/decision/taxonomy/persistent_vomiting/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: persistent_vomiting
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: persistent_vomiting_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: persistent_vomiting_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/persistent_vomiting/flows/safety_screen.yaml b/decision/taxonomy/persistent_vomiting/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..efd8317b1c8910620e5f258729d9b3da1b3daea6
--- /dev/null
+++ b/decision/taxonomy/persistent_vomiting/flows/safety_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: safety_screen
+type: screening
+domain: persistent_vomiting
+
+required_slots:
+  - vomiting_frequency
+  - last_kept_fluids
+  - medications_kept_down
+  - associated_symptoms
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "vomiting frequency"
+        - "last kept fluids"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - vomiting_frequency
+      - last_kept_fluids
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "medications kept down"
+        - "associated symptoms"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - medications_kept_down
+      - associated_symptoms
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/decision/taxonomy/persistent_vomiting/rules.yaml b/decision/taxonomy/persistent_vomiting/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..fb25336f6b766670201acb000e37e28ac71809d3
--- /dev/null
+++ b/decision/taxonomy/persistent_vomiting/rules.yaml
@@ -0,0 +1,27 @@
+domain: persistent_vomiting
+target_risk_class: R2
+
+decision_rules:
+  - id: persistent_vomiting_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: persistent_vomiting_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: persistent_vomiting_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: persistent_vomiting_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/persistent_vomiting/triggers.yaml b/decision/taxonomy/persistent_vomiting/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..86454d704e1e67ca522ae0d3dfd8fe973c3aaf36
--- /dev/null
+++ b/decision/taxonomy/persistent_vomiting/triggers.yaml
@@ -0,0 +1,189 @@
+domain: persistent_vomiting
+priority: 69
+
+lexical_signals:
+  high:
+    phrases:
+      - 'can''t stop vomiting'
+      - 'vomiting all day'
+      - 'can''t keep anything down'
+      - 'persistent vomiting'
+      - 'unable to keep medications down'
+      - 'vomiting blood'
+      - 'been throwing up all day'
+      - 'nothing stays down'
+      - 'puking non-stop'
+      - 'can''t even keep water down'
+      - 'haven''t kept anything down in hours'
+      - 'vomiting for over 24 hours'
+      - 'thrown up everything including my medication'
+      - 'projectile vomiting'
+      - 'vomiting so much I can''t stand up'
+      - 'been sick constantly since yesterday'
+      - 'can''t hold down any fluids at all'
+      - 'my child has been throwing up non-stop'
+      - 'everything I swallow comes right back up'
+      - 'haven''t been able to drink anything all day'
+    regex:
+      - 'can''?t\s+(stop\s+vomiting|keep\s+(anything|food|meds|water|liquid)\s+down)'
+      - 'vomit.{0,15}(all\s+day|won''?t\s+stop|non-?stop|constant|hour)'
+      - '(throw|threw|puking).{0,15}(everything|all\s+day|non-?stop|constant)'
+      - 'nothing\s+(stay|staying|kept)\s+down'
+      - '(been|keep)\s+(throwing\s+up|vomiting|puking)'
+      - 'vomit.{0,15}(blood|red|coffee\s+ground|dark\s+brown)'
+      - '(haven''?t|has\s+not)\s+(kept|held).{0,15}(anything|food|fluid|water|liquid)\s+down'
+      - 'projectile\s+vomit'
+      - '(vomit|throw|sick|puk).{0,15}(over|more\s+than)\s+\d+\s+hour'
+      - '(vomit|throw|sick|puk).{0,15}(since\s+yesterday|since\s+last\s+night|all\s+night)'
+      - 'can''?t\s+(hold|keep)\s+down\s+(any\s+)?fluid'
+  medium:
+    phrases:
+      - 'throwing up repeatedly'
+      - 'vomiting since last night'
+      - 'nausea and vomiting won''t stop'
+      - 'keep throwing up'
+      - 'can''t keep water down'
+      - 'vomiting after every meal'
+      - 'threw up several times'
+      - 'dry heaving'
+      - 'everything comes back up'
+      - 'stomach won''t settle'
+      - 'keeps coming up'
+      - 'bile coming up'
+      - 'even water comes back up'
+      - 'tried crackers and threw them up'
+      - 'sipping and it comes right back'
+      - 'haven''t been able to eat'
+      - 'mouth is so dry from being sick'
+      - 'lips are cracked and I keep vomiting'
+      - 'not peeing much and still throwing up'
+      - 'feeling really weak from vomiting'
+      - 'been sick about ten times today'
+      - 'heaving but nothing comes up anymore'
+      - 'bringing up green stuff'
+      - 'was sick three times in an hour'
+      - 'wretching every few minutes'
+      - 'stomach is in knots and I keep being sick'
+      - 'head is pounding from throwing up so much'
+      - 'eyes are bloodshot from puking'
+      - 'throat is raw from being sick'
+      - 'can only manage tiny sips and those come up too'
+      - 'tried anti-sickness tablets and threw them up'
+      - 'my urine is really dark and I keep being sick'
+      - 'toddler has been sick all morning'
+      - 'diarrhoea and vomiting together'
+      # --- MINIMIZER coverage ---
+      - "I've just been a bit sick"
+      - "it's probably just a bug"
+      - "threw up once or twice, nothing major"
+      - "just a bit nauseous really"
+      - "stomach is a bit off"
+      - "been feeling kind of queasy"
+      - "threw up but I'm probably fine"
+      - "was sick a few times but nothing to worry about"
+      - "just an upset stomach I think"
+      - "a little bit of vomiting, probably something I ate"
+    regex:
+      - '(threw|throw|vomit|puk).{0,20}(multiple|several|many|few)\s+times?'
+      - '(nause|vomit|throw).{0,20}(worse|getting\s+worse|won''?t\s+stop)'
+      - '(food|eat|drink|water|liquid).{0,20}(comes?\s+back|stays?\s+down|keep\s+down)'
+      - 'dry\s+heav'
+      - '(bile|yellow|green).{0,15}(coming|came|com[ei]s?)\s+up'
+      - '(sip|tried|ate).{0,20}(came|comes?|threw|throw).{0,10}(back|up)'
+      - '(mouth|lips|tongue).{0,15}(dry|cracked|parched).{0,20}(sick|vomit|throw)'
+      - '(not|barely|hardly)\s+(pee|urinat).{0,20}(sick|vomit|throw)'
+      - '(weak|shaky|trembly|exhausted).{0,20}(vomit|throw|sick|puk)'
+      - '(sick|vomit|threw\s+up|thrown\s+up).{0,10}\d+\s+times?'
+      - '\d+\s+times?.{0,10}(sick|vomit|threw\s+up|thrown\s+up)'
+      - '(wretch|retch|heav).{0,15}(every|few|couple)\s+(minute|hour)'
+      - '(throat|voice).{0,10}(raw|sore|hoarse).{0,20}(sick|vomit|throw)'
+      - '(anti[- ]?sick|anti[- ]?emetic|ondansetron|cyclizine|metoclopramide).{0,20}(threw|throw|came|come|vomit)'
+      - '(dark|orange|brown)\s+(urine|pee|wee).{0,20}(sick|vomit|throw)'
+      - '(diarrh|diarr).{0,15}(vomit|throw|sick|puk)'
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(just|only).{0,10}(a\\s+)?(little|bit|touch).{0,10}(sick|nause|queasy|vomit)"
+      - "(probably|might be).{0,10}(just|nothing|a bug|food|something I ate).{0,15}(sick|vomit|threw|nause)"
+      - "(threw|throw|thrown|vomit|sick).{0,15}(once|twice|couple|few).{0,15}(nothing|fine|okay|not that bad)"
+      - "(stomach|tummy|belly).{0,10}(a\\s+)?(bit|little|kind of|sort of).{0,10}(off|upset|queasy|unsettled|dodgy)"
+  low:
+    partials:
+      - 'vomiting'
+      - 'throwing up'
+      - 'nausea'
+      - 'emesis'
+      - 'puking'
+      - 'dry heaving'
+      - 'retching'
+      - 'coming back up'
+      - 'being sick'
+      - 'feeling sick'
+      - 'can''t eat'
+      - 'stomach bug'
+      - 'gastro'
+      - 'dehydrated'
+      - 'dark urine'
+      - 'bile'
+      - 'heaving'
+      - 'wretching'
+
+negation_handling:
+  patterns:
+    - 'no vomiting'
+    - 'stopped throwing up'
+    - 'keeping food down'
+    - 'nausea resolved'
+    - 'stomach settled'
+    - 'vomiting stopped'
+    - 'was sick but feeling better now'
+    - 'held down breakfast'
+    - 'kept the water down this time'
+    - 'managed to eat something'
+    - 'anti-sickness tablets are working'
+    - 'only felt nauseous but did not vomit'
+    - 'nausea has passed'
+    - 'stomach has calmed down'
+    - 'able to keep fluids down now'
+    - 'last vomited hours ago and feeling better'
+    - 'tolerating sips of water'
+    - 'no further episodes'
+    - 'eating and drinking normally again'
+    - 'just a bit queasy but not actually sick'
+    # --- poor oral intake / appetite context (R1 suppression) ---
+    - "just not hungry"
+    - "no appetite"
+    - "food doesn't taste good"
+    - "skipping meals"
+    - "forcing myself to eat"
+    - "not eating much"
+    - "appetite is poor"
+    - "don't feel like eating"
+    - "food doesn't appeal"
+    # --- Phase 5: R1 false escalation reduction ---
+    # Appetite / hunger context (not vomiting)
+    - "just not hungry"
+    - "no appetite lately"
+    - "food doesn't taste good"
+    - "lost my appetite"
+    - "appetite has been off"
+    - "don't feel like eating"
+    # Eating habits (without vomiting)
+    - "skipping meals"
+    - "forcing myself to eat"
+    - "eating less than usual"
+    - "not eating as much"
+    - "smaller portions"
+    - "picking at food"
+    # Post-procedure appetite context
+    - "post-surgery appetite"
+    - "recovering appetite"
+    - "appetite improving"
+    - "appetite coming back"
+    - "starting to eat again"
+    # Routine / administrative context
+    - "routine follow-up about eating"
+    - "checking on nutrition"
+    - "nutrition question"
+    - "dietary question"
+    - "eating habits question"
+    - "weight loss follow-up"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/phq2_positive/flows/clarify.yaml b/decision/taxonomy/phq2_positive/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5344d40c61e8483d9e6461a160dbae1aff74894a
--- /dev/null
+++ b/decision/taxonomy/phq2_positive/flows/clarify.yaml
@@ -0,0 +1,26 @@
+flow_id: clarify
+type: clarification
+domain: phq2_positive
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: phq2_clarify
+      goal: "Ask the patient to tell more about how they have been feeling emotionally"
+      tone: warm_empathetic
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "depression"
+        - "PHQ"
+        - "screening"
+      max_questions: 1
+    collects:
+      - phq2_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/phq2_positive/flows/followup_referral.yaml b/decision/taxonomy/phq2_positive/flows/followup_referral.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..30dd634b780dfe6d4477efba068c170f43711e58
--- /dev/null
+++ b/decision/taxonomy/phq2_positive/flows/followup_referral.yaml
@@ -0,0 +1,25 @@
+flow_id: followup_referral
+type: resolution
+domain: phq2_positive
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: phq2_followup_referral
+      goal: "Thank the patient for sharing and inform them their care team will follow up. Do NOT reveal any score or clinical interpretation."
+      tone: warm_empathetic
+      must_include:
+        - "care team"
+        - "thank you for sharing"
+      must_not:
+        - "score"
+        - "PHQ"
+        - "depression"
+        - "elevated"
+        - "positive"
+        - "screening result"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/phq2_positive/flows/phq2_screen.yaml b/decision/taxonomy/phq2_positive/flows/phq2_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..82c35d41c39122f2f321e8c2e2cf3128409d1115
--- /dev/null
+++ b/decision/taxonomy/phq2_positive/flows/phq2_screen.yaml
@@ -0,0 +1,52 @@
+flow_id: phq2_screen
+type: screening
+domain: phq2_positive
+
+required_slots:
+  - phq2_interest
+  - phq2_mood
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: phq2_screen_step1
+      goal: "Administer the first PHQ-2 item: assess loss of interest or pleasure over the past two weeks"
+      tone: warm_empathetic
+      must_include:
+        - "past couple of weeks"
+      must_ask:
+        - "Over the past two weeks, how often have you had little interest or pleasure in doing things?"
+      must_not:
+        - "depression score"
+        - "PHQ"
+        - "screening tool"
+        - "test"
+      max_questions: 1
+    collects:
+      - phq2_interest
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: phq2_screen_step2
+      goal: "Administer the second PHQ-2 item: assess feeling down, depressed, or hopeless over the past two weeks"
+      tone: warm_empathetic
+      must_include:
+        - "past couple of weeks"
+      must_ask:
+        - "And over the past two weeks, how often have you felt down, depressed, or hopeless?"
+      must_not:
+        - "depression score"
+        - "PHQ"
+        - "screening tool"
+        - "test"
+      max_questions: 1
+    collects:
+      - phq2_mood
+
+exit:
+  on_complete: evaluate_concern
+  on_concern: followup_referral
+  on_low_risk: followup_referral
+  on_unclear: followup_referral
diff --git a/decision/taxonomy/phq2_positive/rules.yaml b/decision/taxonomy/phq2_positive/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..02cd068cfdce3097eb0d2b2950a66bcf24c543a3
--- /dev/null
+++ b/decision/taxonomy/phq2_positive/rules.yaml
@@ -0,0 +1,27 @@
+domain: phq2_positive
+target_risk_class: R1
+
+decision_rules:
+  - id: phq2_positive_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: phq2_screen
+
+  - id: phq2_positive_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: phq2_screen
+
+  - id: phq2_positive_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: phq2_positive_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: followup_referral
diff --git a/decision/taxonomy/phq2_positive/triggers.yaml b/decision/taxonomy/phq2_positive/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4ec5601156151de8a8b4baf03bd1752bac0625f9
--- /dev/null
+++ b/decision/taxonomy/phq2_positive/triggers.yaml
@@ -0,0 +1,76 @@
+domain: phq2_positive
+priority: 38
+
+lexical_signals:
+  high:
+    phrases:
+      - "feeling down all the time"
+      - "lost interest in everything"
+      - "hopeless about the future"
+      - "don't enjoy anything anymore"
+      - "don't care about anything"
+      - "what's the point of anything"
+      - "nothing matters anymore"
+      - "feeling worthless"
+      - "no motivation to do anything"
+      - "can't find pleasure in anything"
+      - "life feels pointless"
+      - "don't want to get out of bed"
+      - "crying all the time"
+      - "don't care anymore about anything"
+      - "everything feels empty"
+      - "no interest in things I used to enjoy"
+    regex:
+      - "(feeling|been|feel)\\s+(down|depressed|hopeless|worthless).{0,15}(all\\s+the\\s+time|every\\s+day|constantly|always)"
+      - "(lost|no|little|don't\\s+have)\\s+(interest|pleasure|motivation|enjoyment).{0,15}(in|for|to\\s+do).{0,10}(anything|things|life)"
+      - "(don't|doesn't|can't)\\s+(care|enjoy|find\\s+pleasure).{0,15}(anymore|any\\s+more|about\\s+anything)"
+      - "(what's\\s+the\\s+point|nothing\\s+matters|life\\s+feels?\\s+pointless|everything\\s+feels?\\s+empty)"
+  medium:
+    phrases:
+      - "feeling down"
+      - "little interest in things"
+      - "hopeless"
+      - "not enjoying things"
+      - "depressed lately"
+      - "don't care anymore"
+      - "feeling blue"
+      - "not myself lately"
+      - "lost motivation"
+      - "hard to get going"
+      - "things feel heavy"
+      - "low mood"
+      - "feeling empty"
+    regex:
+      - "(feeling|been|feel)\\s+(down|depressed|hopeless|blue|empty|low)"
+      - "(little|no|lost)\\s+(interest|motivation|enjoyment|pleasure)"
+      - "(not|don't)\\s+(enjoy|care).{0,10}(things|anymore|about)"
+  low:
+    partials:
+      - "depressed"
+      - "down"
+      - "hopeless"
+      - "no interest"
+      - "blue"
+      - "low mood"
+
+negation_handling:
+  patterns:
+    - "not depressed"
+    - "not feeling down"
+    - "feeling good"
+    - "enjoying life"
+    - "doing well"
+    - "feeling fine"
+    - "in a good mood"
+    - "feeling positive"
+    - "no depression"
+    - "not hopeless"
+    - "mood is good"
+    - "have interest in things"
+    - "enjoying my hobbies"
+    - "feeling like myself"
+    - "motivated"
+    - "feeling upbeat"
+    - "not blue"
+    - "mood has been great"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/poor_oral_intake/flows/clarify.yaml b/decision/taxonomy/poor_oral_intake/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4a0b6bf180334c6b64c7303e1b1d37b58dd91911
--- /dev/null
+++ b/decision/taxonomy/poor_oral_intake/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: poor_oral_intake
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: poor_oral_intake_clarify
+      goal: "Ask patient to describe their poor oral intake symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - poor_oral_intake_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/poor_oral_intake/flows/escalate_r1.yaml b/decision/taxonomy/poor_oral_intake/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c80b8481a925f837ce3cac107bbfeb61adc8c152
--- /dev/null
+++ b/decision/taxonomy/poor_oral_intake/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: poor_oral_intake
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/poor_oral_intake/flows/handoff.yaml b/decision/taxonomy/poor_oral_intake/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f58bb522228589fb46f79479a1cf043749046e87
--- /dev/null
+++ b/decision/taxonomy/poor_oral_intake/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: poor_oral_intake
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: poor_oral_intake_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: poor_oral_intake_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/poor_oral_intake/rules.yaml b/decision/taxonomy/poor_oral_intake/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9a69d36c140c445af342cafcfe1325033e8df3ee
--- /dev/null
+++ b/decision/taxonomy/poor_oral_intake/rules.yaml
@@ -0,0 +1,21 @@
+domain: poor_oral_intake
+target_risk_class: R1
+
+decision_rules:
+  - id: poor_oral_intake_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r1
+
+  - id: poor_oral_intake_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r1
+
+  - id: poor_oral_intake_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/poor_oral_intake/triggers.yaml b/decision/taxonomy/poor_oral_intake/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a6c689dda81ce8bab4eea3288b3123055a5c7a97
--- /dev/null
+++ b/decision/taxonomy/poor_oral_intake/triggers.yaml
@@ -0,0 +1,67 @@
+domain: poor_oral_intake
+priority: 42
+
+lexical_signals:
+  high:
+    phrases:
+      - "can't eat anything"
+      - "haven't eaten in days"
+      - "losing weight rapidly"
+      - "no appetite at all since discharge"
+      - "unable to eat or drink"
+      - "unintended weight loss"
+      - "can't keep anything down"
+      - "not drinking any fluids"
+      - "haven't had anything to eat or drink"
+      - "food makes me sick"
+      - "can't swallow anything"
+      - "lost a lot of weight"
+      - "haven't been able to eat since surgery"
+      - "completely lost my appetite"
+    regex:
+      - "(can'?t|unable\\s+to)\\s+(eat|drink|swallow|keep)"
+      - "haven'?t\\s+(eaten|had\\s+anything\\s+to\\s+eat)"
+      - "(losing|lost)\\s+(a\\s+lot\\s+of\\s+)?weight"
+      - "(no|lost|zero|completely\\s+lost)\\s+(my\\s+)?appetite"
+      - "not\\s+(eating|drinking)\\s+(anything|at\\s+all|much)"
+  medium:
+    phrases:
+      - "not eating much"
+      - "appetite is very poor"
+      - "losing weight since discharge"
+      - "barely eating anything"
+      - "don't want to eat"
+      - "only eating a little bit"
+      - "food doesn't taste good"
+      - "not hungry at all"
+      - "skipping meals"
+      - "forcing myself to eat"
+      - "just not interested in food"
+      - "eating less and less"
+  low:
+    partials:
+      - "poor appetite"
+      - "not eating"
+      - "weight loss"
+      - "no appetite"
+      - "can't eat"
+      - "not hungry"
+
+negation_handling:
+  patterns:
+    - "eating well"
+    - "appetite is fine"
+    - "no weight loss"
+    - "appetite is good"
+    - "eating normally"
+    - "eating fine"
+    - "appetite has returned"
+    - "appetite is back"
+    - "eating better"
+    - "keeping food down"
+    - "haven't had anything like that"
+    - "haven't had anything of the sort"
+    - "no, haven't had anything"
+    - "haven't had any of that"
+    - "no, nothing like that"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/post_discharge_engagement/flows/appointments_check.yaml b/decision/taxonomy/post_discharge_engagement/flows/appointments_check.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9f512ec72c1e388edd1dc9b15c90ea09a4c54afc
--- /dev/null
+++ b/decision/taxonomy/post_discharge_engagement/flows/appointments_check.yaml
@@ -0,0 +1,22 @@
+flow_id: appointments_check
+type: ask
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pde_appointments_check
+      goal: "Check if the patient has follow-up appointments scheduled and can get to them"
+      tone: warm_professional
+      must_include:
+        - "follow-up"
+        - "appointment"
+      must_ask:
+        - "do you have your follow-up appointments scheduled"
+      must_not:
+        - "must"
+        - "have to"
+      max_questions: 1
+    collects:
+      - appointment_barrier
diff --git a/decision/taxonomy/post_discharge_engagement/flows/closing.yaml b/decision/taxonomy/post_discharge_engagement/flows/closing.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..391c095ff2b079a9c509f6d1f84ae87bd8d96437
--- /dev/null
+++ b/decision/taxonomy/post_discharge_engagement/flows/closing.yaml
@@ -0,0 +1,18 @@
+flow_id: closing
+type: respond
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: pde_closing
+      goal: "Thank the patient, summarize next steps, and close warmly"
+      tone: warm_professional
+      must_include:
+        - "thank you"
+        - "care team"
+      must_ask: []
+      must_not:
+        - "goodbye forever"
+      max_questions: 0
diff --git a/decision/taxonomy/post_discharge_engagement/flows/discharge_context.yaml b/decision/taxonomy/post_discharge_engagement/flows/discharge_context.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6bb17f66d6cbe27984b0d782d5da2a7e29ae84e3
--- /dev/null
+++ b/decision/taxonomy/post_discharge_engagement/flows/discharge_context.yaml
@@ -0,0 +1,22 @@
+flow_id: discharge_context
+type: ask
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pde_discharge_context
+      goal: "Confirm discharge details and set context for the call"
+      tone: warm_professional
+      must_include:
+        - "discharged"
+        - "recovery"
+      must_ask:
+        - "how things have been going since you left the hospital"
+      must_not:
+        - "diagnos"
+        - "should be"
+      max_questions: 1
+    collects:
+      - discharge_context_ack
diff --git a/decision/taxonomy/post_discharge_engagement/flows/emergency_plan_teachback.yaml b/decision/taxonomy/post_discharge_engagement/flows/emergency_plan_teachback.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..58511dc4c39b5004b526d67e20c09200490ecb65
--- /dev/null
+++ b/decision/taxonomy/post_discharge_engagement/flows/emergency_plan_teachback.yaml
@@ -0,0 +1,21 @@
+flow_id: emergency_plan_teachback
+type: ask
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pde_emergency_plan
+      goal: "Confirm the patient knows what to do and who to call in an emergency"
+      tone: warm_professional
+      must_include:
+        - "emergency"
+      must_ask:
+        - "if something feels wrong, what would you do"
+      must_not:
+        - "scare"
+        - "panic"
+      max_questions: 1
+    collects:
+      - emergency_plan_ack
diff --git a/decision/taxonomy/post_discharge_engagement/flows/general_status.yaml b/decision/taxonomy/post_discharge_engagement/flows/general_status.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..04cac9b29a929d95168e35e9ceca4b379a2fa20f
--- /dev/null
+++ b/decision/taxonomy/post_discharge_engagement/flows/general_status.yaml
@@ -0,0 +1,21 @@
+flow_id: general_status
+type: ask
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pde_general_status
+      goal: "Ask the patient how they are feeling overall today"
+      tone: warm_empathetic
+      must_include:
+        - "feeling"
+      must_ask:
+        - "how are you feeling overall today"
+      must_not:
+        - "diagnos"
+        - "should be"
+      max_questions: 1
+    collects:
+      - health_status
diff --git a/decision/taxonomy/post_discharge_engagement/flows/home_services_equipment.yaml b/decision/taxonomy/post_discharge_engagement/flows/home_services_equipment.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4d0641aa22c0e2b3ab34998540c7ad4bfb86f979
--- /dev/null
+++ b/decision/taxonomy/post_discharge_engagement/flows/home_services_equipment.yaml
@@ -0,0 +1,21 @@
+flow_id: home_services_equipment
+type: ask
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pde_home_services
+      goal: "Check if the patient needs any home health services or equipment"
+      tone: warm_professional
+      must_include:
+        - "home"
+      must_ask:
+        - "do you have everything you need at home, like equipment or home health services"
+      must_not:
+        - "must"
+        - "should"
+      max_questions: 1
+    collects:
+      - home_issue
diff --git a/decision/taxonomy/post_discharge_engagement/flows/intro_permission.yaml b/decision/taxonomy/post_discharge_engagement/flows/intro_permission.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..65f1b6af991bf5158e3381746c8592a3e4b3991a
--- /dev/null
+++ b/decision/taxonomy/post_discharge_engagement/flows/intro_permission.yaml
@@ -0,0 +1,22 @@
+flow_id: intro_permission
+type: ask
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pde_intro_permission
+      goal: "Introduce yourself and ask permission to walk through a structured check-in"
+      tone: warm_professional
+      must_include:
+        - "post-discharge check-in"
+        - "recovery"
+      must_ask:
+        - "walk through a few topics together"
+      must_not:
+        - "diagnos"
+        - "medical advice"
+      max_questions: 1
+    collects:
+      - agenda_consent
diff --git a/decision/taxonomy/post_discharge_engagement/flows/meds_reconciliation.yaml b/decision/taxonomy/post_discharge_engagement/flows/meds_reconciliation.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c41061316e39254dd40a9b6d721575d8b1ed964d
--- /dev/null
+++ b/decision/taxonomy/post_discharge_engagement/flows/meds_reconciliation.yaml
@@ -0,0 +1,21 @@
+flow_id: meds_reconciliation
+type: ask
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pde_meds_reconciliation
+      goal: "Check that the patient has their medications and can take them without barriers"
+      tone: warm_professional
+      must_include:
+        - "medication"
+      must_ask:
+        - "have you been able to get and take all your medications"
+      must_not:
+        - "must"
+        - "have to"
+      max_questions: 1
+    collects:
+      - meds_barrier
diff --git a/decision/taxonomy/post_discharge_engagement/flows/pending_tests_check.yaml b/decision/taxonomy/post_discharge_engagement/flows/pending_tests_check.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..720c34d2a22076ce8dad19c7ad3be330d7ff4fcc
--- /dev/null
+++ b/decision/taxonomy/post_discharge_engagement/flows/pending_tests_check.yaml
@@ -0,0 +1,21 @@
+flow_id: pending_tests_check
+type: ask
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pde_pending_tests
+      goal: "Ask if the patient has any pending test results they are waiting for"
+      tone: warm_professional
+      must_include:
+        - "tests"
+        - "results"
+      must_ask:
+        - "are you waiting on any test results"
+      must_not:
+        - "diagnos"
+      max_questions: 1
+    collects:
+      - pending_tests_status
diff --git a/decision/taxonomy/post_discharge_engagement/flows/problem_solving.yaml b/decision/taxonomy/post_discharge_engagement/flows/problem_solving.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7846897cd6d426c3da342e23f6bf897e346e36eb
--- /dev/null
+++ b/decision/taxonomy/post_discharge_engagement/flows/problem_solving.yaml
@@ -0,0 +1,18 @@
+flow_id: problem_solving
+type: respond
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: pde_problem_solving
+      goal: "Summarize any barriers identified and confirm tasks that will be created to help"
+      tone: warm_reassuring
+      must_include:
+        - "help"
+      must_ask: []
+      must_not:
+        - "your fault"
+        - "should have"
+      max_questions: 0
diff --git a/decision/taxonomy/post_discharge_engagement/flows/symptom_review_collector.yaml b/decision/taxonomy/post_discharge_engagement/flows/symptom_review_collector.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..24deb1fa0ef362aa988fdbcc3c310338b5614d79
--- /dev/null
+++ b/decision/taxonomy/post_discharge_engagement/flows/symptom_review_collector.yaml
@@ -0,0 +1,21 @@
+flow_id: symptom_review_collector
+type: ask
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pde_symptom_review
+      goal: "Ask about any new or worsening symptoms since discharge"
+      tone: calm_professional
+      must_include:
+        - "symptoms"
+      must_ask:
+        - "any new or worsening symptoms since you came home"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 1
+    collects:
+      - symptom_free_text
diff --git a/decision/taxonomy/post_discharge_engagement/flows/teachback_diagnosis.yaml b/decision/taxonomy/post_discharge_engagement/flows/teachback_diagnosis.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c0a95a9391e75595f3f4ebb94632705d11a71613
--- /dev/null
+++ b/decision/taxonomy/post_discharge_engagement/flows/teachback_diagnosis.yaml
@@ -0,0 +1,22 @@
+flow_id: teachback_diagnosis
+type: ask
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pde_teachback_diagnosis
+      goal: "Teach-back: ask the patient to describe their main health problem in their own words"
+      tone: warm_curious
+      must_include:
+        - "own words"
+      must_ask:
+        - "what is the main health problem you were treated for"
+      must_not:
+        - "wrong"
+        - "incorrect"
+        - "test"
+      max_questions: 1
+    collects:
+      - teachback_main_problem
diff --git a/decision/taxonomy/post_discharge_engagement/flows/teachback_warning_signs.yaml b/decision/taxonomy/post_discharge_engagement/flows/teachback_warning_signs.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7547425687648e44ec5f354101f24615b96ec30f
--- /dev/null
+++ b/decision/taxonomy/post_discharge_engagement/flows/teachback_warning_signs.yaml
@@ -0,0 +1,22 @@
+flow_id: teachback_warning_signs
+type: ask
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pde_teachback_warning_signs
+      goal: "Teach-back: ask the patient to name warning signs they should watch for"
+      tone: warm_curious
+      must_include:
+        - "warning signs"
+      must_ask:
+        - "what warning signs were you told to watch for"
+      must_not:
+        - "wrong"
+        - "incorrect"
+        - "test"
+      max_questions: 1
+    collects:
+      - teachback_warning_signs
diff --git a/decision/taxonomy/post_discharge_engagement/flows/wrap_up.yaml b/decision/taxonomy/post_discharge_engagement/flows/wrap_up.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..75a168d5a8d6c1ee8da1c5404b8b6e8e048df3dc
--- /dev/null
+++ b/decision/taxonomy/post_discharge_engagement/flows/wrap_up.yaml
@@ -0,0 +1,16 @@
+flow_id: wrap_up
+type: respond
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: pde_wrap_up
+      goal: "Final sign-off after agenda is complete"
+      tone: warm_professional
+      must_include:
+        - "take care"
+      must_ask: []
+      must_not: []
+      max_questions: 0
diff --git a/decision/taxonomy/post_discharge_engagement/rules.yaml b/decision/taxonomy/post_discharge_engagement/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e703b18d789826fa7d2c25d6cf189f9e4777d617
--- /dev/null
+++ b/decision/taxonomy/post_discharge_engagement/rules.yaml
@@ -0,0 +1,86 @@
+domain: post_discharge_engagement
+
+decision_rules:
+  - id: pde_intro_permission
+    if:
+      agenda_step: intro_permission
+    then:
+      flow: intro_permission
+
+  - id: pde_discharge_context
+    if:
+      agenda_step: discharge_context
+    then:
+      flow: discharge_context
+
+  - id: pde_teachback_diagnosis
+    if:
+      agenda_step: teachback_diagnosis
+    then:
+      flow: teachback_diagnosis
+
+  - id: pde_teachback_warning_signs
+    if:
+      agenda_step: teachback_warning_signs
+    then:
+      flow: teachback_warning_signs
+
+  - id: pde_general_status
+    if:
+      agenda_step: general_status
+    then:
+      flow: general_status
+
+  - id: pde_symptom_review
+    if:
+      agenda_step: symptom_review
+    then:
+      flow: symptom_review_collector
+
+  - id: pde_meds_reconciliation
+    if:
+      agenda_step: meds_reconciliation
+    then:
+      flow: meds_reconciliation
+
+  - id: pde_appointments_check
+    if:
+      agenda_step: appointments_check
+    then:
+      flow: appointments_check
+
+  - id: pde_pending_tests
+    if:
+      agenda_step: pending_tests
+    then:
+      flow: pending_tests_check
+
+  - id: pde_home_services
+    if:
+      agenda_step: home_services
+    then:
+      flow: home_services_equipment
+
+  - id: pde_problem_solving
+    if:
+      agenda_step: problem_solving
+    then:
+      flow: problem_solving
+
+  - id: pde_emergency_plan
+    if:
+      agenda_step: emergency_plan
+    then:
+      flow: emergency_plan_teachback
+
+  - id: pde_closing
+    if:
+      agenda_step: closing
+    then:
+      flow: closing
+
+  - id: pde_wrap_up
+    if:
+      agenda_step: wrap_up
+    then:
+      flow: wrap_up
diff --git a/decision/taxonomy/post_discharge_engagement/triggers.yaml b/decision/taxonomy/post_discharge_engagement/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f231ce7f67d5db61d4182f25edcdad0e60361a16
--- /dev/null
+++ b/decision/taxonomy/post_discharge_engagement/triggers.yaml
@@ -0,0 +1,8 @@
+domain: post_discharge_engagement
+priority: 0
+
+# Empty signals — this domain is agenda-driven, not nomination-driven.
+# It becomes the default control path after consent completes with no
+# safety signals.  The engine activates it by setting agenda_step, not
+# through lexical nomination.
+lexical_signals: {}
diff --git a/decision/taxonomy/post_discharge_fever/flows/clarify.yaml b/decision/taxonomy/post_discharge_fever/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..bf28c28e664f19be1fc55e4b627f8bf218da71f6
--- /dev/null
+++ b/decision/taxonomy/post_discharge_fever/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: post_discharge_fever
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: post_discharge_fever_clarify
+      goal: "Ask patient to describe their post discharge fever symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - post_discharge_fever_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/post_discharge_fever/flows/escalate_r2.yaml b/decision/taxonomy/post_discharge_fever/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f8b95af461ad0cafb5da907af858a82e95be5a76
--- /dev/null
+++ b/decision/taxonomy/post_discharge_fever/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: post_discharge_fever
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/post_discharge_fever/flows/handoff.yaml b/decision/taxonomy/post_discharge_fever/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..78cdeb8aa2e9a3147915b4f2e3fe793f4fe7986f
--- /dev/null
+++ b/decision/taxonomy/post_discharge_fever/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: post_discharge_fever
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: post_discharge_fever_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: post_discharge_fever_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/post_discharge_fever/flows/safety_screen.yaml b/decision/taxonomy/post_discharge_fever/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7cd739ef6e98ea7241a3555a592afdde077893c6
--- /dev/null
+++ b/decision/taxonomy/post_discharge_fever/flows/safety_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: safety_screen
+type: screening
+domain: post_discharge_fever
+
+required_slots:
+  - temperature_reading
+  - fever_onset
+  - other_symptoms
+  - recent_procedure
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "temperature reading"
+        - "fever onset"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - temperature_reading
+      - fever_onset
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "other symptoms"
+        - "recent procedure"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - other_symptoms
+      - recent_procedure
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/decision/taxonomy/post_discharge_fever/rules.yaml b/decision/taxonomy/post_discharge_fever/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d4e7402d7b1f39ed9d136035c27ee375cc8bd3da
--- /dev/null
+++ b/decision/taxonomy/post_discharge_fever/rules.yaml
@@ -0,0 +1,27 @@
+domain: post_discharge_fever
+target_risk_class: R2
+
+decision_rules:
+  - id: post_discharge_fever_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: post_discharge_fever_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: post_discharge_fever_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: post_discharge_fever_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/post_discharge_fever/triggers.yaml b/decision/taxonomy/post_discharge_fever/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8d96f7600f704d427d9f0a621cc7c4e9b760e010
--- /dev/null
+++ b/decision/taxonomy/post_discharge_fever/triggers.yaml
@@ -0,0 +1,173 @@
+domain: post_discharge_fever
+priority: 68
+
+lexical_signals:
+  high:
+    phrases:
+      - "fever of 101 since discharge"
+      - "temperature is 102"
+      - "high fever after surgery"
+      - "spiked a fever post-discharge"
+      - "fever over 38.5"
+      - "post-op fever"
+      - "got home from the hospital and started feeling warm"
+      - "discharged and now I feel hot"
+      - "fever since coming home from hospital"
+      - "acting feverish since surgery"
+      - "temperature hit 103"
+      - "thermometer says 101.5"
+      - "fever and chills after my surgery"
+      - "burning up since I got home from the hospital"
+      - "running 102 since they sent me home"
+      - "came home from surgery and now have a fever"
+      - "spiked to 104 after getting discharged"
+      - "temp keeps climbing since my procedure"
+      - "incision is red and I have a fever"
+      - "fever and the wound looks infected"
+    regex:
+      - "(fever|temp|temperature)\\s+(of\\s+|was\\s+|is\\s+|said\\s+)?1(0[1-9]|[1-9]\\d)"
+      - "fever.*post.?(op|discharge|surgery)"
+      - "(discharg|hospital|surgery|procedure).*(fever|hot|warm|feverish|shaky)"
+      - "(fever|hot|warm|feverish).*(discharg|hospital|surgery|procedure|came home|got home)"
+      - "(temp|temperature).*(100\\.[4-9]|10[1-9]|1[1-9]\\d)"
+      - "(thermometer|temp).{0,10}(say|read|show|said|reads|shows).{0,5}(10[1-9]|1[1-9]\\d)"
+      - "(burn|burning)\\s+up.{0,15}(since|after).{0,10}(home|hospital|discharg|surgery)"
+      - "(running|spiked?|hit|reach).{0,5}(a\\s+)?(10[1-9]|1[1-9]\\d).{0,15}(since|after).{0,15}(home|hospital|discharg|surgery|sent)"
+      - "(came|got|been)\\s+home.{0,10}(from\\s+)?(surgery|hospital|procedure).{0,15}(fever|temp|hot)"
+      - "(fever|temp).{0,10}(keep|keeps|kept).{0,10}(climb|go|ris|creep)"
+      - "(incision|wound|site|stitches).{0,15}(red|warm|hot|infect).{0,15}fever"
+      - "fever.{0,15}(incision|wound|site|stitches).{0,15}(red|warm|hot|infect)"
+  medium:
+    phrases:
+      - "fever since coming home"
+      - "temperature elevated since discharge"
+      - "running a fever"
+      - "feel feverish and was just discharged"
+      - "fever after procedure"
+      - "temperature keeps going up"
+      - "sweaty and a little shaky"
+      - "feel hot and shaky"
+      - "started feeling warm"
+      - "got home from the hospital"
+      - "incision area feels sore"
+      - "shivery episode"
+      - "flipping between sweaty and cold"
+      - "forehead feels warm"
+      - "acting off since I got home"
+      - "something went wrong after the hospital"
+      - "woke up soaked in sweat after my surgery"
+      - "teeth chattering and I just had surgery"
+      - "my skin feels hot to the touch since I got home"
+      - "body aches and chills since the procedure"
+      - "I just do not feel right since they let me go"
+      - "came home yesterday and now I feel terrible"
+      - "whole body is shaking since the operation"
+      - "been running hot since they took my catheter out"
+      - "my face is flushed and I had surgery two days ago"
+      - "night sweats since coming home from hospital"
+      - "alternating between hot and cold since my procedure"
+      - "kids say my forehead is really warm"
+      - "feel like I am coming down with something after my operation"
+    regex:
+      - "(sweaty|shaky|shiver|chill).*(discharg|hospital|surgery|home)"
+      - "(discharg|hospital|surgery|home).*(sweaty|shaky|shiver|chill|warm|hot)"
+      - "(feel|feeling)\\s+(kinda?|kind\\s+of|a\\s+bit|sort\\s+of\\s+)?(warm|hot|feverish)"
+      - "(got|came|been)\\s+home\\s+(from\\s+)?(the\\s+)?hospital"
+      - "(just|recently)\\s+(discharged|released|got\\s+out|came\\s+home)"
+      - "after\\s+(my|the|his|her)\\s+\\w+\\s+surgery"
+      - "(shiver|chill|rigor|sweating).*(and|then).*(cold|hot|warm)"
+      - "after\\s+(my|the|his|her)\\s+(gallbladder|knee|hip|heart|back|shoulder|hernia)\\s+surgery"
+      - "after\\s+(a|the)\\s+(knee|hip)\\s+arthroscop"
+      - "discharged\\s+yesterday"
+      - "body\\s+is.*doing\\s+this"
+      - "just\\s+got.*home\\s+and\\s+now"
+      - "feel\\s+(kind\\s+of\\s+)?warm"
+      - "feel\\s+(kinda?)\\s+warm"
+      - "feel\\s+(really\\s+)?hot\\s+and\\s+shaky"
+      - "feels?\\s+a\\s+bit\\s+warm"
+      - "not\\s+acting\\s+right"
+      - "(woke|wake).{0,5}up.{0,10}(soaked|drenched|dripping).{0,10}(in\\s+)?sweat"
+      - "(teeth|body).{0,5}(chatter|shak).{0,10}(since|after).{0,10}(surgery|procedure|operation|hospital)"
+      - "skin.{0,10}(hot|warm|burning).{0,10}(to\\s+the\\s+)?touch"
+      - "(body\\s+ache|aching|achy).{0,15}(chill|shiver|shak).{0,15}(since|after|procedure|surgery)"
+      - "(don[']?t|do\\s+not)\\s+feel\\s+right\\s+since"
+      - "(came|got)\\s+home\\s+(yesterday|today|last\\s+night).{0,15}(feel|now)"
+      - "(whole\\s+)?body.{0,5}(is\\s+)?(shak|trembl)"
+      - "(running|been)\\s+hot\\s+since"
+      - "(face|cheeks?|skin).{0,10}(flush|red|hot|warm)"
+      - "night\\s+sweat.{0,15}(since|after|home|hospital|surgery)"
+      - "(hot\\s+and\\s+cold|cold\\s+and\\s+hot|alternating).{0,15}(since|after|procedure|surgery)"
+      - "(wife|husband|kid|son|daughter|spouse|partner).{0,10}(say|said|notice).{0,10}(warm|hot|fever|flush)"
+      - "(coming\\s+down|getting\\s+sick|caught\\s+something).{0,15}(after|since|operation|surgery|procedure)"
+  low:
+    partials:
+      - "fever"
+      - "temperature elevated"
+      - "feverish"
+      - "sweaty and shaky"
+      - "feel warm"
+      - "feel hot"
+      - "chills"
+      - "shivery"
+      - "discharged"
+      - "after surgery"
+      - "post-op"
+      - "since hospital"
+      - "night sweats"
+      - "body aches"
+      - "burning up"
+      - "flushed"
+      - "rigors"
+      - "cold sweats"
+
+negation_handling:
+  patterns:
+    - "no fever"
+    - "temperature is normal"
+    - "fever broke"
+    - "not feverish"
+    - "chills resolved"
+    - "temp is 98.6"
+    - "temperature came back down"
+    - "fever went away"
+    - "feeling better now"
+    - "no longer feverish"
+    - "temperature has been normal since discharge"
+    - "checked my temp and it is normal"
+    - "was warm but it passed"
+    - "chills went away on their own"
+    - "fever was from the anesthesia and it resolved"
+    - "only had a low grade temp briefly"
+    - "not running a fever anymore"
+    - "temp came down after tylenol"
+    - "sweating but temp is normal"
+    - "no fever no chills"
+    # --- post-procedure incontinence context (R1 scenarios) ---
+    - "incontinence"
+    - "urine leakage"
+    - "leaking urine"
+    - "bladder control"
+    - "bladder surgery"
+    - "prostate surgery"
+    - "prostate procedure"
+    - "pelvic floor"
+    - "wearing pads"
+    - "catheter removal"
+    - "after the catheter"
+    - "leaking since surgery"
+    - "didn't take my temperature"
+    - "haven't checked my temperature"
+    # --- wound care / healing context ---
+    - "healing"
+    - "wound care"
+    - "dressing change"
+    - "bandage change"
+    - "wound check"
+    - "stitches"
+    - "wound looks"
+    - "incision looks"
+    # --- scheduling context ---
+    - "scheduling"
+    - "schedule an appointment"
+    - "make an appointment"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/post_procedure_incontinence/flows/clarify.yaml b/decision/taxonomy/post_procedure_incontinence/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9d022b641727d7ad4ae57b297e7284634903dab2
--- /dev/null
+++ b/decision/taxonomy/post_procedure_incontinence/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: post_procedure_incontinence
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: post_procedure_incontinence_clarify
+      goal: "Ask patient to describe their post procedure incontinence symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - post_procedure_incontinence_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/post_procedure_incontinence/flows/escalate_r1.yaml b/decision/taxonomy/post_procedure_incontinence/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c628d59cc92fbe322d902f3748dd65ca91aa8e33
--- /dev/null
+++ b/decision/taxonomy/post_procedure_incontinence/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: post_procedure_incontinence
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/post_procedure_incontinence/flows/handoff.yaml b/decision/taxonomy/post_procedure_incontinence/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..dff1a9029c79df8bb3321f7c167e62c7a104feff
--- /dev/null
+++ b/decision/taxonomy/post_procedure_incontinence/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: post_procedure_incontinence
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: post_procedure_incontinence_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: post_procedure_incontinence_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/post_procedure_incontinence/rules.yaml b/decision/taxonomy/post_procedure_incontinence/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..904939b536fc5dafe25340c7920ee29fa0e3e523
--- /dev/null
+++ b/decision/taxonomy/post_procedure_incontinence/rules.yaml
@@ -0,0 +1,21 @@
+domain: post_procedure_incontinence
+target_risk_class: R1
+
+decision_rules:
+  - id: post_procedure_incontinence_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r1
+
+  - id: post_procedure_incontinence_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r1
+
+  - id: post_procedure_incontinence_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/post_procedure_incontinence/triggers.yaml b/decision/taxonomy/post_procedure_incontinence/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3aebd4914ce0bdfa542d5ed1694aeb007caf51bf
--- /dev/null
+++ b/decision/taxonomy/post_procedure_incontinence/triggers.yaml
@@ -0,0 +1,51 @@
+domain: post_procedure_incontinence
+priority: 37
+
+lexical_signals:
+  high:
+    phrases:
+      - "can't hold my urine since surgery"
+      - "new incontinence after procedure"
+      - "leaking urine since operation"
+      - "fecal incontinence after surgery"
+      - "lost bladder control post-op"
+      - "new bowel incontinence since procedure"
+      - "wetting myself since the surgery"
+      - "can't control my bladder anymore"
+      - "urine just comes out on its own"
+      - "having accidents since the operation"
+      - "peeing on myself"
+      - "can't make it to the bathroom in time"
+      - "soiling myself since discharge"
+    regex:
+      - "(incontinence|leaking|wetting|accidents).*(surgery|procedure|operation|post.?op|since)"
+      - "(can'?t|lost|losing)\\s+(hold|control).*\\s*(bladder|urine|bowel)"
+      - "(bladder|bowel)\\s+(control|problem|issue).*\\s*(since|after|post)"
+  medium:
+    phrases:
+      - "trouble controlling bladder since surgery"
+      - "some urinary leaking"
+      - "incontinence since procedure"
+      - "bladder issues after surgery"
+      - "bowel control problems post-op"
+      - "leaking a little bit"
+      - "dribbling urine"
+      - "wearing pads for leaking"
+      - "bladder doesn't feel right"
+      - "having some accidents"
+      - "trouble holding it"
+  low:
+    partials:
+      - "incontinence"
+      - "leaking urine"
+      - "bladder control"
+      - "wetting"
+      - "accidents"
+      - "can't hold it"
+
+negation_handling:
+  patterns:
+    - "no incontinence"
+    - "bladder control fine"
+    - "no leaking"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/pregnancy_emergency/flows/clarify.yaml b/decision/taxonomy/pregnancy_emergency/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..62aec608eda11d92f553ad13adb5a6034d871476
--- /dev/null
+++ b/decision/taxonomy/pregnancy_emergency/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: pregnancy_emergency
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pregnancy_emergency_clarify
+      goal: "Ask patient to describe their pregnancy emergency symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - pregnancy_emergency_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/pregnancy_emergency/flows/escalate_r3.yaml b/decision/taxonomy/pregnancy_emergency/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..aa71bacc64b59c802ce6ea56d41cf6cd8a282498
--- /dev/null
+++ b/decision/taxonomy/pregnancy_emergency/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: pregnancy_emergency
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Inform patient this requires immediate clinical attention and they will be transferred"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/pregnancy_emergency/flows/handoff.yaml b/decision/taxonomy/pregnancy_emergency/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1daf9986d4b0aa2fc9b702a147166d0afe149237
--- /dev/null
+++ b/decision/taxonomy/pregnancy_emergency/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: pregnancy_emergency
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: pregnancy_emergency_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: pregnancy_emergency_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/pregnancy_emergency/rules.yaml b/decision/taxonomy/pregnancy_emergency/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3b49470277d634d3e5ec17ac635dfc940413f68f
--- /dev/null
+++ b/decision/taxonomy/pregnancy_emergency/rules.yaml
@@ -0,0 +1,21 @@
+domain: pregnancy_emergency
+target_risk_class: R3
+
+decision_rules:
+  - id: pregnancy_emergency_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r3
+
+  - id: pregnancy_emergency_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r3
+
+  - id: pregnancy_emergency_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/pregnancy_emergency/triggers.yaml b/decision/taxonomy/pregnancy_emergency/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..130b60aa113879e867daa59fc45a98a94938358f
--- /dev/null
+++ b/decision/taxonomy/pregnancy_emergency/triggers.yaml
@@ -0,0 +1,288 @@
+domain: pregnancy_emergency
+priority: 88
+
+lexical_signals:
+  high:
+    phrases:
+      - "pregnant and bleeding heavily"
+      - "pregnant and fainted"
+      - "pregnancy bleeding"
+      - "heavy vaginal bleeding and pregnant"
+      - "pregnant and passed out"
+      - "pregnant and hemorrhaging"
+      - "pregnant and something's wrong"
+      - "weeks pregnant and bleeding"
+      - "pregnant and cramping badly"
+      - "she's pregnant"
+      # --- caregiver-reported patterns (high confidence) ---
+      - "my wife is pregnant and bleeding"
+      - "my girlfriend is pregnant and bleeding"
+      - "she's bleeding a lot"
+      - "her water broke"
+      - "she's having contractions"
+      - "she can't stop bleeding"
+      - "she's in so much pain"
+      - "something's wrong with my wife"
+      - "something's wrong with my girlfriend"
+      # --- severe symptom combos (high confidence) ---
+      - "pregnant and soaking through pads"
+      - "pregnant and can't stop bleeding"
+      - "pregnant and seeing spots"
+      - "pregnant and terrible headache"
+      - "pregnant and really swollen"
+      - "pregnant and passing clots"
+      - "baby isn't moving at all"
+      - "baby stopped moving"
+      - "no fetal movement"
+      - "baby hasn't moved"
+    regex:
+      - "pregnant\\s+and\\s+(bleeding|faint|passed\\s+out|cramping)"
+      - "\\d+\\s*weeks?\\s+pregnant"
+      - "\\d+\\s*weeks.{0,80}(bleed|cramp|pain|pressure|gush|fluid|contraction|blood)"
+      - "(bleed|cramp|pain|pressure|gush|fluid|contraction|blood).{0,80}\\d+\\s*weeks"
+      - "pregnant.{0,80}bleed"
+      - "bleed.{0,80}pregnant"
+      - "pregnant.{0,80}cramp"
+      - "pregnant.{0,80}(pain|hurt|ache)"
+      - "pregnant.{0,80}(dizzy|faint|passed out|lightheaded)"
+      - "pregnant.{0,80}headache"
+      - "pregnant.{0,80}(swelling|swollen)"
+      - "pregnant.{0,80}(gush|blood|soaking)"
+      - "trimester"
+      - "\\d+\\s*weeks.{0,15}(and|but|,)"
+      - "she'?s\\s+pregnant"
+      - "i'?m\\s+pregnant"
+      # --- caregiver-reported regex (high confidence) ---
+      - "(my\\s+)?(wife|girlfriend|partner|daughter).{0,50}pregnant.{0,50}(bleed|blood|wrong|pain|dizzy|faint)"
+      - "she'?s.{0,40}(bleeding|hemorrhag|contraction|labor|passed\\s+out|faint)"
+      - "her\\s+(water|membranes?).{0,15}(broke|ruptured)"
+      # --- reduced fetal movement (high confidence) ---
+      - "baby.{0,40}(not|hasn't|stopped|quit).{0,20}mov"
+      - "baby.{0,40}(hasn't|not).{0,20}(kick|moved)"
+      - "(haven't|hasn't|not|didn't).{0,30}felt.{0,20}(baby|kick|movement)"
+      - "fetal\\s+movement.{0,25}(decreased|reduced|less|none|stopped)"
+      # --- preeclampsia high confidence signals ---
+      - "pregnant.{0,60}(vision|seeing|see).{0,40}(spot|spark|blur|flash|zig|double)"
+      - "pregnant.{0,60}(severe|terrible|worst|intense|splitting)\\s+headache"
+      - "(\\d+\\s*weeks).{0,60}headache.{0,60}(swol|puff|vision|blur)"
+      # --- bright red / clot bleeding ---
+      - "(bright\\s+red|fresh).{0,30}(blood|bleed).{0,50}pregnant"
+      - "pregnant.{0,50}(bright\\s+red|fresh).{0,30}(blood|bleed)"
+      - "passing.{0,20}clots?.{0,40}pregnant"
+      - "pregnant.{0,40}passing.{0,20}clots?"
+  medium:
+    phrases:
+      - "bleeding during pregnancy"
+      - "pregnant and dizzy"
+      - "pregnancy complication"
+      - "vaginal bleeding while pregnant"
+      - "contractions too early"
+      - "baby isn't moving"
+      - "water broke early"
+      - "leaking fluid and pregnant"
+      - "preeclampsia"
+      - "pregnant and my blood pressure is high"
+      - "really pregnant"
+      - "belly feels tight"
+      - "eight months pregnant"
+      - "eight months along"
+      - "gush of blood"
+      # --- Phase 4: expanded patterns for missed scenarios ---
+      - "lady problems"
+      - "female issue"
+      - "women's trouble"
+      - "spotting and cramping"
+      - "soaked through pads"
+      - "going through pads quickly"
+      # --- Phase 5: additional vaginal bleeding patterns ---
+      - "bleeding more than spotting"
+      - "bleeding won't stop"
+      - "bleeding keeps coming"
+      - "changed pads twice"
+      - "changed pads three times"
+      - "pad is getting full"
+      - "pad soaked in an hour"
+      - "blood when I wipe"
+      - "blood on my underwear"
+      - "clots in the toilet"
+      - "thicker bits"
+      - "bright red blood"
+      # --- reduced fetal movement variations ---
+      - "baby's been quieter"
+      - "baby is quieter"
+      - "baby has been quiet"
+      - "less movement than usual"
+      - "movement has decreased"
+      - "baby moving less"
+      - "baby not as active"
+      - "baby hasn't kicked"
+      - "haven't felt movement"
+      - "not feeling movement"
+      - "the baby's quiet"
+      # --- preterm labor signals ---
+      - "contractions coming"
+      - "timing contractions"
+      - "contractions every few minutes"
+      - "cramping comes and goes"
+      - "tightening comes and goes"
+      - "regular cramping"
+      - "regular tightening"
+      - "preterm labor"
+      - "premature contractions"
+      # --- preeclampsia signals ---
+      - "rings don't fit"
+      - "wedding ring won't come off"
+      - "face is puffy"
+      - "face looks puffy"
+      - "hands are swollen"
+      - "feet are swollen"
+      - "ankles are swollen"
+      - "vision is blurry"
+      - "seeing sparkly things"
+      - "seeing spots"
+      - "sparkly zigzags"
+      - "flashing lights"
+      - "blood pressure is high"
+      - "bp is high"
+      - "high blood pressure and pregnant"
+      - "headache won't go away"
+      - "worst headache"
+      - "terrible headache"
+      - "splitting headache"
+      - "pain under my ribs"
+      - "upper belly pain"
+      - "right sided belly pain"
+      # --- caregiver patterns medium ---
+      - "my wife is bleeding"
+      - "my girlfriend is bleeding"
+      - "my partner is bleeding"
+      - "she keeps bleeding"
+      - "she's been bleeding"
+      - "she's still bleeding"
+      - "she's in pain"
+      - "she's scared"
+      - "she's really worried"
+      - "calling about my wife"
+      - "calling about my girlfriend"
+      - "calling about my partner"
+      # --- euphemistic patterns ---
+      - "lady issues"
+      - "women's issues"
+      - "down there problems"
+      - "feminine problems"
+      - "private area bleeding"
+    regex:
+      - "(baby|fetus).{0,30}(not moving|stopped moving|less movement|moving less)"
+      - "(water|membrane).{0,20}(broke|ruptured|leaking)"
+      - "(gush|sudden).{0,15}(blood|bleed|fluid)"
+      - "(belly|abdomen|stomach).{0,20}(tight|hard|cramping|contracting)"
+      - "really\\s+(far along|pregnant)"
+      - "eight\\s+months\\s+(pregnant|along|preg)"
+      - "\\b(2[0-9]|3[0-9]|4[0-2])\\s*weeks\\b"
+      - "placenta\\s+(previa|abruption|accreta)"
+      - "braxton\\s+hicks.{0,40}(real|actual|not sure|can't tell)"
+      # --- Phase 4: expanded patterns for missed scenarios ---
+      - "(lady|women's|female).{0,10}(problem|issue|trouble)"
+      - "pregnant.{0,40}(seeing|see|vision).{0,20}(sparkle|flash|spot|aura|blur)"
+      - "\\b(ring|rings).{0,20}(don't fit|too tight|too small|won't come off)"
+      - "(went|gone|going).{0,30}(through|using).{0,10}\\d+.{0,5}pad"
+      - "(soak|soaked|soaking).{0,20}(pad|pads|through)"
+      - "probably.{0,30}(nothing|fine).{0,30}(spotting|bleed|cramp)"
+      # --- Phase 5: reduced fetal movement ---
+      - "baby.{0,40}(quieter|quiet|less active|decreased|reduced)"
+      - "baby.{0,40}hasn.{0,10}(moved|kicked|active)"
+      - "(felt|feel|feeling).{0,20}less.{0,20}(movement|kick|active)"
+      - "movement.{0,30}(decreased|reduced|less|quieter)"
+      - "haven.{0,10}felt.{0,30}(move|kick|baby)"
+      # --- preterm labor patterns ---
+      - "contraction.{0,30}(every|regular|coming|started)"
+      - "cramp.{0,30}(every|regular|comes and goes|timing)"
+      - "tighten.{0,30}(every|regular|comes and goes|lets go)"
+      - "(timing|time|counting).{0,20}(contraction|cramp)"
+      # --- preeclampsia variations ---
+      - "(ring|rings).{0,30}(tight|fit|off)"
+      - "(face|hands|feet|ankles).{0,20}(puffy|swollen|swelling)"
+      - "(puffy|swollen|swelling).{0,20}(face|hands|feet|ankles)"
+      - "vision.{0,30}(blur|spark|flash|spot|double|weird)"
+      - "(blur|spark|flash|spot|double|weird).{0,30}vision"
+      - "headache.{0,40}pregnant"
+      - "pregnant.{0,40}headache"
+      - "(pain|ache).{0,20}(rib|right side|upper abdomen)"
+      # --- caregiver regex patterns ---
+      - "(wife|girlfriend|partner|daughter).{0,40}(bleed|blood|pain|cramp|contraction)"
+      - "(calling|call).{0,20}about.{0,20}(wife|girlfriend|partner|daughter|her)"
+      - "she.{0,30}(bleed|blood|cramp|contraction|pain|labor)"
+      # --- gestational age patterns ---
+      - "\\d+\\s*months?\\s+(pregnant|along)"
+      - "(six|seven|eight|nine)\\s+months?\\s+(pregnant|along)"
+      - "due\\s+(date|in).{0,20}(weeks?|months?)"
+      - "expecting.{0,30}(bleed|cramp|pain|dizzy)"
+  low:
+    partials:
+      - "pregnancy bleeding"
+      - "pregnant complication"
+      - "obstetric"
+      - "preeclampsia"
+      - "eclampsia"
+      - "placenta"
+      - "premature labor"
+      - "weeks pregnant"
+      - "months pregnant"
+      - "I'm pregnant"
+      # --- Phase 5: additional low confidence partials ---
+      - "she's pregnant"
+      - "expecting"
+      - "due date"
+      - "fetal"
+      - "baby moving"
+      - "baby kicking"
+      - "third trimester"
+      - "second trimester"
+      - "first trimester"
+      - "gestational"
+      - "prenatal"
+      - "miscarriage"
+      - "contractions"
+      - "water broke"
+      - "amniotic"
+      - "spotting"
+      - "vaginal bleeding"
+      - "cramping and pregnant"
+
+negation_handling:
+  patterns:
+    - "not pregnant"
+    - "no pregnancy complications"
+    - "pregnancy is fine"
+    # --- follow-up/scheduling timeframe context (R1 scenarios) ---
+    - "follow up in"
+    - "follow-up in"
+    - "return in"
+    - "appointment in"
+    - "check back in"
+    - "see you in"
+    - "come back in"
+    - "weeks from now"
+    - "weeks out"
+    - "weeks post"
+    - "weeks since"
+    - "weeks ago"
+    - "days from now"
+    - "days ago"
+    - "weeks after surgery"
+    - "weeks after the procedure"
+    - "week follow-up"
+    - "week follow up"
+    - "week check"
+    - "week appointment"
+    - "post-op"
+    - "post-procedure"
+    - "recovery timeline"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/procedure_anxiety_severe/flows/clarify.yaml b/decision/taxonomy/procedure_anxiety_severe/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d2001f052a28c7f06b9cd74060c2c876e3e93c41
--- /dev/null
+++ b/decision/taxonomy/procedure_anxiety_severe/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: procedure_anxiety_severe
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: procedure_anxiety_clarify
+      goal: "Ask patient to describe how they are feeling about their upcoming surgery"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - procedure_anxiety_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/procedure_anxiety_severe/flows/concern_assessment.yaml b/decision/taxonomy/procedure_anxiety_severe/flows/concern_assessment.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f09400c7cf555d04b28e79f64e68f01a85aa7f8d
--- /dev/null
+++ b/decision/taxonomy/procedure_anxiety_severe/flows/concern_assessment.yaml
@@ -0,0 +1,53 @@
+flow_id: concern_assessment
+type: assessment
+domain: procedure_anxiety_severe
+
+required_slots:
+  - anxiety_severity
+  - cancellation_intent
+  - support_system
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: procedure_anxiety_assess_step1
+      goal: "Understand how severe the patient's anxiety is and whether they are considering cancelling"
+      tone: warm_empathetic
+      must_include:
+        - "understand"
+      must_ask:
+        - "How would you describe how anxious you are feeling right now?"
+        - "Are you thinking about cancelling or postponing the surgery?"
+      must_not:
+        - "overreacting"
+        - "don't worry"
+        - "it's nothing"
+      max_questions: 2
+    collects:
+      - anxiety_severity
+      - cancellation_intent
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: procedure_anxiety_assess_step2
+      goal: "Assess whether the patient has support and what specific concerns are driving the anxiety"
+      tone: warm_empathetic
+      must_include:
+        - "support"
+      must_ask:
+        - "Do you have someone with you or someone you can talk to about this?"
+      must_not:
+        - "overreacting"
+        - "shouldn't feel"
+        - "it's routine"
+      max_questions: 1
+    collects:
+      - support_system
+
+exit:
+  on_complete: evaluate_concern
+  on_concern: handoff
+  on_low_risk: reassure_low_risk
+  on_unclear: handoff
diff --git a/decision/taxonomy/procedure_anxiety_severe/flows/escalate_r2.yaml b/decision/taxonomy/procedure_anxiety_severe/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c98439826a112f45dbdc6c8ed064b84491f73cb2
--- /dev/null
+++ b/decision/taxonomy/procedure_anxiety_severe/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: procedure_anxiety_severe
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: procedure_anxiety_r2_escalation_notice
+      goal: "Inform patient that a nurse will follow up same day about their concerns"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: procedure_anxiety_r2_handoff
+      goal: "Schedule same-day nurse callback with anxiety context"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/procedure_anxiety_severe/flows/handoff.yaml b/decision/taxonomy/procedure_anxiety_severe/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b5e720a03613577a3779fc280bb000cab44b0b37
--- /dev/null
+++ b/decision/taxonomy/procedure_anxiety_severe/flows/handoff.yaml
@@ -0,0 +1,35 @@
+flow_id: handoff
+type: handoff
+domain: procedure_anxiety_severe
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: procedure_anxiety_handoff
+      goal: "Let patient know they will be connected with a surgical counselor who can help address their concerns"
+      tone: warm_empathetic
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+        - "overreacting"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: surgical_counselor
+    urgency: normal
+    response_spec:
+      id: procedure_anxiety_handoff_transfer
+      goal: "Transfer to surgical counselor with anxiety context"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/procedure_anxiety_severe/flows/reassure_low_risk.yaml b/decision/taxonomy/procedure_anxiety_severe/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..acf9fa684488134509097ea13e2ef08a3c2ab360
--- /dev/null
+++ b/decision/taxonomy/procedure_anxiety_severe/flows/reassure_low_risk.yaml
@@ -0,0 +1,22 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: procedure_anxiety_severe
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: procedure_anxiety_reassure
+      goal: "Acknowledge the patient's normal pre-surgical anxiety, validate their feelings, and note their care team will be available"
+      tone: warm_empathetic
+      must_include:
+        - "normal"
+        - "care team"
+      must_not:
+        - "emergency"
+        - "overreacting"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/procedure_anxiety_severe/rules.yaml b/decision/taxonomy/procedure_anxiety_severe/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9d3442c06ee22794ea941683b3707739d395c352
--- /dev/null
+++ b/decision/taxonomy/procedure_anxiety_severe/rules.yaml
@@ -0,0 +1,27 @@
+domain: procedure_anxiety_severe
+target_risk_class: R1
+
+decision_rules:
+  - id: procedure_anxiety_severe_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: concern_assessment
+
+  - id: procedure_anxiety_severe_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: concern_assessment
+
+  - id: procedure_anxiety_severe_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: procedure_anxiety_severe_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/procedure_anxiety_severe/triggers.yaml b/decision/taxonomy/procedure_anxiety_severe/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c178c568fda9cc68821fa337d747e6d68353a85a
--- /dev/null
+++ b/decision/taxonomy/procedure_anxiety_severe/triggers.yaml
@@ -0,0 +1,77 @@
+domain: procedure_anxiety_severe
+priority: 40
+
+lexical_signals:
+  high:
+    phrases:
+      - "can't go through with this"
+      - "too scared for surgery"
+      - "want to cancel my surgery"
+      - "having a panic attack about the procedure"
+      - "don't think I can do this"
+      - "can't do the surgery"
+      - "need to cancel the operation"
+      - "too anxious to go through with it"
+      - "having second thoughts about surgery"
+      - "terrified of going under"
+      - "can't stop thinking about dying during surgery"
+      - "want to back out of the procedure"
+      - "too frightened to have the operation"
+      - "I am not going through with this surgery"
+      - "please cancel my procedure"
+      - "I refuse to have the surgery"
+      - "panicking about anesthesia"
+    regex:
+      - "(can't|cannot|don't\\s+think\\s+I\\s+can|unable\\s+to|refuse\\s+to).{0,15}(go\\s+through|do|have|handle).{0,10}(surgery|procedure|operation)"
+      - "(cancel|back\\s+out|call\\s+off|postpone).{0,15}(surgery|procedure|operation)"
+      - "(too|so|extremely|really).{0,10}(scared|frightened|terrified|anxious|panick).{0,15}(surgery|procedure|operation|anesthesia)"
+      - "(panic|panick|anxiety).{0,10}(attack|episode).{0,15}(surgery|procedure|operation)"
+      - "(terrified|petrified).{0,10}(of|about).{0,15}(surgery|procedure|operation|anesthesia|going\\s+under|dying)"
+  medium:
+    phrases:
+      - "nervous about surgery"
+      - "worried about the procedure"
+      - "anxious about going under"
+      - "scared about anesthesia"
+      - "dreading the surgery"
+      - "surgery makes me anxious"
+      - "worried about the operation"
+      - "stressed about the procedure"
+      - "can't sleep thinking about surgery"
+      - "really nervous about tomorrow"
+      - "anxiety about the anesthesia"
+      - "scared about what could go wrong"
+      - "worried something bad will happen"
+    regex:
+      - "(nervous|worried|anxious|scared|stressed|dread).{0,15}(about|for|of).{0,10}(surgery|procedure|operation|anesthesia|going\\s+under)"
+      - "(surgery|procedure|operation|anesthesia).{0,15}(makes?\\s+me|is\\s+making\\s+me).{0,10}(nervous|worried|anxious|scared)"
+      - "(can't|cannot)\\s+(sleep|relax|stop\\s+thinking).{0,15}(surgery|procedure|operation)"
+  low:
+    partials:
+      - "nervous"
+      - "worried about surgery"
+      - "scared"
+      - "anxious about procedure"
+      - "surgery anxiety"
+
+negation_handling:
+  patterns:
+    - "not too nervous"
+    - "handling it okay"
+    - "a little nervous but fine"
+    - "ready for surgery"
+    - "feeling prepared"
+    - "not worried about the surgery"
+    - "feeling confident"
+    - "looking forward to getting it done"
+    - "ready to go"
+    - "just a little nervous but that's normal"
+    - "managing my anxiety"
+    - "doing okay with it"
+    - "not too scared"
+    - "feeling okay about surgery"
+    - "prepared for the procedure"
+    - "not anxious"
+    - "calm about surgery"
+    - "at peace with it"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/progressive_weakness/flows/clarify.yaml b/decision/taxonomy/progressive_weakness/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4360d99463f0a9351060db5f8655effbbc8d8d3d
--- /dev/null
+++ b/decision/taxonomy/progressive_weakness/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: progressive_weakness
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: progressive_weakness_clarify
+      goal: "Ask patient to describe their progressive weakness symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - progressive_weakness_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/progressive_weakness/flows/escalate_r1.yaml b/decision/taxonomy/progressive_weakness/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ab6b456be1eaface0c7875b73e04b32eafb17257
--- /dev/null
+++ b/decision/taxonomy/progressive_weakness/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: progressive_weakness
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/progressive_weakness/flows/handoff.yaml b/decision/taxonomy/progressive_weakness/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8aae6d049ed1a5c8ded0fab0d68b409a176d1f4d
--- /dev/null
+++ b/decision/taxonomy/progressive_weakness/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: progressive_weakness
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: progressive_weakness_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: progressive_weakness_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/progressive_weakness/rules.yaml b/decision/taxonomy/progressive_weakness/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1b5f5b4c104ba86c3baca67414cdbb258de95e65
--- /dev/null
+++ b/decision/taxonomy/progressive_weakness/rules.yaml
@@ -0,0 +1,21 @@
+domain: progressive_weakness
+target_risk_class: R1
+
+decision_rules:
+  - id: progressive_weakness_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r1
+
+  - id: progressive_weakness_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r1
+
+  - id: progressive_weakness_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/progressive_weakness/triggers.yaml b/decision/taxonomy/progressive_weakness/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..69793a01d3031d218e95a24fb06eef1b7968e1d4
--- /dev/null
+++ b/decision/taxonomy/progressive_weakness/triggers.yaml
@@ -0,0 +1,56 @@
+domain: progressive_weakness
+priority: 36
+
+lexical_signals:
+  high:
+    phrases:
+      - "getting weaker every day"
+      - "progressive weakness"
+      - "can barely stand up now"
+      - "losing strength rapidly"
+      - "weakness getting worse each day"
+      - "fatigue worsening daily"
+      - "can't even get out of bed"
+      - "legs are giving out"
+      - "so weak I can't walk"
+      - "my strength is declining"
+      - "weaker and weaker"
+      - "muscles are getting weaker"
+      - "can barely move"
+      - "too weak to do anything"
+    regex:
+      - "(progressive|getting\\s+worse|worsening)\\s+(weakness|fatigue)"
+      - "weaker\\s+every\\s+day"
+      - "(can'?t|can\\s+barely|unable\\s+to)\\s+(stand|walk|get\\s+(up|out))"
+      - "weak(er|ness)?\\s+(and\\s+weak|getting|is\\s+(worse|getting))"
+      - "(too|so)\\s+weak"
+  medium:
+    phrases:
+      - "feeling weaker than before"
+      - "less strength than last week"
+      - "getting more fatigued"
+      - "weakness increasing"
+      - "not as strong as before discharge"
+      - "having trouble getting around"
+      - "my legs feel weak"
+      - "arms feel heavy"
+      - "exhausted all the time"
+      - "no energy at all"
+      - "feeling very weak"
+      - "more tired than usual"
+  low:
+    partials:
+      - "weakness"
+      - "fatigue"
+      - "weak"
+      - "losing strength"
+      - "no energy"
+      - "exhausted"
+      - "tired all the time"
+
+negation_handling:
+  patterns:
+    - "feeling stronger"
+    - "strength improving"
+    - "not weak anymore"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/recurrent_falls/flows/clarify.yaml b/decision/taxonomy/recurrent_falls/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7fe9adf8eb3bd093dd1775b11425f303ff3352b6
--- /dev/null
+++ b/decision/taxonomy/recurrent_falls/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: recurrent_falls
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: recurrent_falls_clarify
+      goal: "Ask patient to describe their recurrent falls symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - recurrent_falls_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/recurrent_falls/flows/escalate_r1.yaml b/decision/taxonomy/recurrent_falls/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8e0130dafe22a1d5bc4da9042a4a2d0365c84671
--- /dev/null
+++ b/decision/taxonomy/recurrent_falls/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: recurrent_falls
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/recurrent_falls/flows/handoff.yaml b/decision/taxonomy/recurrent_falls/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..231262914df049de925c57485acbbe2b8b36217b
--- /dev/null
+++ b/decision/taxonomy/recurrent_falls/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: recurrent_falls
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: recurrent_falls_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: recurrent_falls_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/recurrent_falls/rules.yaml b/decision/taxonomy/recurrent_falls/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a8ffed8e1bb648b8fc15b6feda1b9e12cd368de3
--- /dev/null
+++ b/decision/taxonomy/recurrent_falls/rules.yaml
@@ -0,0 +1,21 @@
+domain: recurrent_falls
+target_risk_class: R1
+
+decision_rules:
+  - id: recurrent_falls_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r1
+
+  - id: recurrent_falls_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r1
+
+  - id: recurrent_falls_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/recurrent_falls/triggers.yaml b/decision/taxonomy/recurrent_falls/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..dfb4589773666ba4b6d6c7b4bf715e5dc984268e
--- /dev/null
+++ b/decision/taxonomy/recurrent_falls/triggers.yaml
@@ -0,0 +1,54 @@
+domain: recurrent_falls
+priority: 45
+
+lexical_signals:
+  high:
+    phrases:
+      - "keep falling"
+      - "fell again today"
+      - "third fall this week"
+      - "recurrent falls"
+      - "falling frequently"
+      - "keep losing my balance and falling"
+      - "I fell down again"
+      - "fell twice this week"
+      - "fallen multiple times"
+      - "keep tripping and falling"
+      - "I fall every day"
+      - "can't stop falling"
+      - "another fall last night"
+      - "falling at home"
+    regex:
+      - "(keep|recurrent|frequent|multiple|repeated)\\s+fall"
+      - "fell\\s+(again|down|twice|three|multiple)"
+      - "fall(ing|en|s)?\\s+(every|all|at\\s+home|frequently|multiple|more)"
+      - "(keep|can'?t\\s+stop)\\s+(fall|trip)"
+  medium:
+    phrases:
+      - "fell a couple times this week"
+      - "another fall today"
+      - "falling more often"
+      - "unsteady and falling"
+      - "had another fall recently"
+      - "I fell yesterday"
+      - "almost fell a few times"
+      - "my balance is terrible"
+      - "tripping over things"
+      - "stumbling a lot"
+      - "I keep stumbling"
+  low:
+    partials:
+      - "falls"
+      - "falling"
+      - "unsteady"
+      - "balance problems"
+      - "stumbling"
+      - "tripping"
+      - "fell down"
+
+negation_handling:
+  patterns:
+    - "no falls"
+    - "steady on my feet"
+    - "balance is good"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/reproducible_chest_discomfort/flows/clarify.yaml b/decision/taxonomy/reproducible_chest_discomfort/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0df74a1baecad8254cebc076890e014be6613580
--- /dev/null
+++ b/decision/taxonomy/reproducible_chest_discomfort/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: reproducible_chest_discomfort
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: reproducible_chest_discomfort_clarify
+      goal: "Ask patient to describe their reproducible chest discomfort symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - reproducible_chest_discomfort_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/reproducible_chest_discomfort/flows/escalate_r1.yaml b/decision/taxonomy/reproducible_chest_discomfort/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..23ac5372d2364883bb108750fab7942aea2cdb0f
--- /dev/null
+++ b/decision/taxonomy/reproducible_chest_discomfort/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: reproducible_chest_discomfort
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/reproducible_chest_discomfort/flows/handoff.yaml b/decision/taxonomy/reproducible_chest_discomfort/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a3964223dce8f85b279b283230e880f4de9eea63
--- /dev/null
+++ b/decision/taxonomy/reproducible_chest_discomfort/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: reproducible_chest_discomfort
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: reproducible_chest_discomfort_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: reproducible_chest_discomfort_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/reproducible_chest_discomfort/rules.yaml b/decision/taxonomy/reproducible_chest_discomfort/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e86f41dbac4bf79bee8d1abb7d604e76af882724
--- /dev/null
+++ b/decision/taxonomy/reproducible_chest_discomfort/rules.yaml
@@ -0,0 +1,21 @@
+domain: reproducible_chest_discomfort
+target_risk_class: R1
+
+decision_rules:
+  - id: reproducible_chest_discomfort_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r1
+
+  - id: reproducible_chest_discomfort_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r1
+
+  - id: reproducible_chest_discomfort_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/reproducible_chest_discomfort/triggers.yaml b/decision/taxonomy/reproducible_chest_discomfort/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..12e5997189266d2df7d97c8d6b8a765a83fa8fcc
--- /dev/null
+++ b/decision/taxonomy/reproducible_chest_discomfort/triggers.yaml
@@ -0,0 +1,154 @@
+domain: reproducible_chest_discomfort
+priority: 38
+
+lexical_signals:
+  high:
+    phrases:
+      - "chest hurts when I press on it"
+      - "chest pain only when I move a certain way"
+      - "reproducible chest pain"
+      - "chest pain is positional"
+      - "chest discomfort when I twist or turn"
+      - "chest wall tenderness when pressing"
+      - "pain in my chest when I push on it"
+      - "if I press right here on my chest it hurts"
+      - "I can make the chest pain happen by moving"
+      - "chest pain goes away when I stop moving"
+      - "hurts only when I reach overhead"
+      - "chest pain when I take a deep breath and twist"
+      - "sore spot on my chest wall"
+      - "tender spot on my sternum when I press"
+      - "chest pain that I can reproduce every time"
+      - "it only hurts when I push on that exact spot"
+      - "my chest is sore to the touch"
+      - "the pain comes back every time I lift something"
+      - "chest pain when I bend forward"
+      - "I can point to the exact spot that hurts"
+      - "hurts right here when I press"
+      - "musculoskeletal chest pain"
+      - "costochondritis"
+      - "chest wall pain when I cough"
+      - "sharp chest pain when I twist my torso"
+      - "tender right on the breastbone"
+      - "it hurts in my chest only when I push on that rib"
+      - "chest pain that comes and goes with arm movement"
+    regex:
+      - "chest.*(press|position|reproduc|movement|twist)"
+      - "chest\\s+wall\\s+tender"
+      - "chest.*(hurts?|pain|sore).*(press|push|touch|poke)"
+      - "(press|push|touch|poke).*(chest|sternum|rib).*(hurts?|pain|sore|tender)"
+      - "chest.*(pain|hurts?|sore).*(move|twist|turn|bend|reach|lift|stretch)"
+      - "(move|twist|turn|bend|reach|lift|stretch).*(chest|sternum).*(hurts?|pain|sore)"
+      - "chest.*(pain|hurts?).*every\\s+time\\s+I"
+      - "can\\s+make.*(chest|pain).*happen"
+      - "point\\s+to.*(exact|specific)\\s+spot"
+      - "sore\\s+spot.*(chest|sternum|rib)"
+      - "costochondritis"
+      - "chest\\s+wall\\s+(pain|sore|tender|discomfort)"
+      - "(one|specific|exact|certain)\\s+spot.*(chest|sternum|rib)"
+      - "chest.*(pain|hurts?).*(arm|shoulder)\\s+(move|motion|reach)"
+      - "tender.*(right|directly)\\s+on.*(sternum|breastbone|rib)"
+  medium:
+    phrases:
+      - "chest pain comes with certain movement"
+      - "discomfort in chest when pressing"
+      - "chest wall tenderness"
+      - "musculoskeletal chest pain"
+      - "chest pain with certain positions only"
+      - "my chest has been sore"
+      - "chest feels bruised"
+      - "feels like a pulled muscle in my chest"
+      - "it hurts when I sneeze or cough in my chest"
+      - "my ribs are sore"
+      - "pain between my ribs"
+      - "sharp pain when I take a deep breath"
+      - "chest pain worse when I lie on that side"
+      - "it comes and goes with how I move"
+      - "chest pain for a few days but only with movement"
+      - "I think I pulled something in my chest"
+      - "the spot is tender if I rub it"
+      - "hurts when I stretch"
+      - "pain right along my breastbone"
+      - "intercostal pain"
+      - "my chest hurts after working out"
+      - "sore right where my ribs connect"
+      - "it feels muscular not like a heart thing"
+      - "pain is on the surface not deep"
+      - "worse when I take a big breath"
+      - "chest is achy when I roll over in bed"
+      - "hurts more when I carry something heavy"
+      - "my chest has been sore since I moved furniture"
+      - "feels like something is strained in my chest"
+      - "chest tightness only in certain positions"
+      - "sore along the cartilage near my ribs"
+      - "pain flares up when I use my arm on that side"
+    regex:
+      - "chest.*(bruise|pull|strain|muscle|sore)"
+      - "(pull|strain|muscle).*(chest|rib|sternum)"
+      - "chest.*(sneeze|cough|laugh|yawn).*(hurts?|pain|worse)"
+      - "(sneeze|cough|laugh|yawn).*(chest|rib).*(hurts?|pain|worse)"
+      - "chest.*(comes?\\s+and\\s+go|off\\s+and\\s+on|intermittent).*mov"
+      - "(rib|ribs|sternum|breastbone).*(sore|tender|pain|hurts?)"
+      - "deep\\s+breath.*(chest|rib).*(hurts?|pain|sharp)"
+      - "chest.*(deep\\s+breath|breath).*(hurts?|pain|sharp|worse)"
+      - "chest.*(surface|superficial|muscular|not\\s+deep)"
+      - "(work|exercise|lift|gym).*(chest|rib).*(sore|pain|hurts?)"
+      - "chest.*(work|exercise|lift|gym).*(sore|pain|hurts?)"
+      - "intercostal"
+      - "chest.*(achy|ache|sore).*(roll|lie|lay|sleep|bed|side)"
+      - "(carry|haul|lift|move).*(heavy|furniture|box).*(chest|rib).*(sore|pain|hurts?)"
+      - "chest.*(strained|strain|tight).*(position|certain|only)"
+      - "cartilage.*(rib|chest).*(sore|tender|pain)"
+      - "(flare|worse|hurts?\\s+more).*(arm|shoulder).*(that|same)\\s+side"
+  low:
+    partials:
+      - "chest tender"
+      - "positional chest"
+      - "reproducible chest"
+      - "chest sore"
+      - "rib pain"
+      - "chest bruised"
+      - "chest pulled"
+      - "sternum sore"
+      - "breastbone pain"
+      - "chest movement"
+      - "chest when I press"
+      - "chest when I move"
+      - "sharp chest"
+      - "sore ribs"
+      - "chest wall"
+      - "surface pain chest"
+      - "muscular chest pain"
+      - "chest strain"
+      - "chest cartilage"
+      - "rib cartilage"
+      - "chest achy"
+      - "chest tight position"
+
+negation_handling:
+  patterns:
+    - "chest doesn't hurt with movement"
+    - "no chest tenderness"
+    - "chest pain gone"
+    - "chest pain not related to movement"
+    - "pressing on chest doesn't hurt"
+    - "no tenderness to palpation"
+    - "no reproducible pain"
+    - "chest is not sore anymore"
+    - "chest wall not tender"
+    - "no pain when I press on it"
+    - "the soreness went away"
+    - "no musculoskeletal component"
+    - "not positional"
+    - "pain doesn't change with movement"
+    - "not affected by position"
+    - "not tender to touch"
+    - "no chest wall tenderness"
+    - "chest feels fine now"
+    - "pain resolved completely"
+    - "no longer sore"
+    - "ribs are not tender"
+    - "costochondritis resolved"
+    - "chest strain healed"
+    - "no pain with deep breathing"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/scheduling/flows/cancel.yaml b/decision/taxonomy/scheduling/flows/cancel.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0aa61153b62e638ad543b176f78aa682d7e973e8
--- /dev/null
+++ b/decision/taxonomy/scheduling/flows/cancel.yaml
@@ -0,0 +1,27 @@
+flow_id: cancel
+type: service
+domain: scheduling
+
+required_slots:
+  - existing_appointment
+  - cancel_reason
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: cancel_gather
+      goal: "Confirm which appointment to cancel and reason"
+      tone: helpful_professional
+      must_include:
+        - "cancel"
+      must_ask:
+        - "which appointment"
+      must_not: []
+      max_questions: 2
+    collects:
+      - existing_appointment
+      - cancel_reason
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/scheduling/flows/clarify.yaml b/decision/taxonomy/scheduling/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..41bbd32fc20571409c361ae61652df043447b11b
--- /dev/null
+++ b/decision/taxonomy/scheduling/flows/clarify.yaml
@@ -0,0 +1,23 @@
+flow_id: clarify
+type: clarification
+domain: scheduling
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: scheduling_clarify
+      goal: "Ask patient to clarify their scheduling need"
+      tone: gentle_professional
+      must_include:
+        - "appointment"
+      must_ask:
+        - "help me understand"
+      must_not: []
+      max_questions: 2
+    collects:
+      - scheduling_intent
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/scheduling/flows/new_appt.yaml b/decision/taxonomy/scheduling/flows/new_appt.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..495aaf46bd1025b8f6472d0567bca703bca96eb4
--- /dev/null
+++ b/decision/taxonomy/scheduling/flows/new_appt.yaml
@@ -0,0 +1,32 @@
+flow_id: new_appt
+type: service
+domain: scheduling
+
+required_slots:
+  - preferred_date
+  - preferred_time
+  - provider_preference
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: schedule_gather
+      goal: "Gather appointment preferences from patient"
+      tone: helpful_professional
+      must_include:
+        - "appointment"
+      must_ask:
+        - "when would you like"
+        - "provider"
+      must_not:
+        - "diagnos"
+      max_questions: 2
+    collects:
+      - preferred_date
+      - preferred_time
+      - provider_preference
+
+exit:
+  on_complete: end
+  on_unclear: clarify
diff --git a/decision/taxonomy/scheduling/flows/reschedule.yaml b/decision/taxonomy/scheduling/flows/reschedule.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..09d906f232f6b5cc18acfd21da61a5c1db8a3baa
--- /dev/null
+++ b/decision/taxonomy/scheduling/flows/reschedule.yaml
@@ -0,0 +1,28 @@
+flow_id: reschedule
+type: service
+domain: scheduling
+
+required_slots:
+  - existing_appointment
+  - new_preferred_date
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: reschedule_gather
+      goal: "Confirm existing appointment and gather new preferred time"
+      tone: helpful_professional
+      must_include:
+        - "reschedule"
+      must_ask:
+        - "current appointment"
+        - "new date"
+      must_not: []
+      max_questions: 2
+    collects:
+      - existing_appointment
+      - new_preferred_date
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/scheduling/rules.yaml b/decision/taxonomy/scheduling/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d7014330ccab29c8775115f7f5ce7551da13f2f7
--- /dev/null
+++ b/decision/taxonomy/scheduling/rules.yaml
@@ -0,0 +1,30 @@
+domain: scheduling
+
+decision_rules:
+  - id: scheduling_new_appt
+    if:
+      confidence: high
+    then:
+      flow: new_appt
+
+  - id: scheduling_reschedule
+    if:
+      confidence: medium
+      slots_present:
+        - existing_appointment
+    then:
+      flow: reschedule
+
+  - id: scheduling_cancel
+    if:
+      confidence: medium
+      slots_present:
+        - cancel_request
+    then:
+      flow: cancel
+
+  - id: scheduling_low
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/scheduling/triggers.yaml b/decision/taxonomy/scheduling/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d40debee3f7fd7a0fde7220de4cf70ab42bac26a
--- /dev/null
+++ b/decision/taxonomy/scheduling/triggers.yaml
@@ -0,0 +1,33 @@
+domain: scheduling
+priority: 30
+
+lexical_signals:
+  high:
+    phrases:
+      - "schedule an appointment"
+      - "book an appointment"
+      - "need to see the doctor"
+      - "reschedule"
+      - "cancel my appointment"
+    regex:
+      - "(schedule|book|make)\\s+(an?\\s+)?appointment"
+  medium:
+    phrases:
+      - "when can I come in"
+      - "next available"
+      - "follow up visit"
+    partials:
+      - "appointment"
+      - "schedule"
+  low:
+    phrases:
+      - "need to come in"
+    partials:
+      - "visit"
+      - "office"
+
+negation_handling:
+  patterns:
+    - "don't need an appointment"
+    - "no appointment needed"
+  action: suppress
diff --git a/decision/taxonomy/scheduling_barrier/flows/barrier_assessment.yaml b/decision/taxonomy/scheduling_barrier/flows/barrier_assessment.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..628ec1a938d0384c27bc2ee2dfdadefb89d4debb
--- /dev/null
+++ b/decision/taxonomy/scheduling_barrier/flows/barrier_assessment.yaml
@@ -0,0 +1,52 @@
+flow_id: barrier_assessment
+type: assessment
+domain: scheduling_barrier
+
+required_slots:
+  - barrier_type
+  - resource_need
+  - preferred_appointment_time
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: scheduling_barrier_assess_step1
+      goal: "Identify the specific barrier preventing the patient from completing their care"
+      tone: warm_empathetic
+      must_include:
+        - "understand"
+        - "help"
+      must_ask:
+        - "Can you tell me more about what's making it hard to get to your appointment?"
+        - "Is this related to transportation, cost, work schedule, or something else?"
+      must_not:
+        - "you need to figure this out"
+        - "that's not our problem"
+      max_questions: 2
+    collects:
+      - barrier_type
+      - resource_need
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: scheduling_barrier_assess_step2
+      goal: "Understand scheduling preferences and explore what would help the patient access care"
+      tone: warm_empathetic
+      must_include:
+        - "options"
+      must_ask:
+        - "What time or day would work best for you if we could help arrange something?"
+      must_not:
+        - "you have to"
+        - "no excuse"
+      max_questions: 1
+    collects:
+      - preferred_appointment_time
+
+exit:
+  on_complete: evaluate_concern
+  on_concern: resource_referral
+  on_low_risk: scheduling_assist
+  on_unclear: resource_referral
diff --git a/decision/taxonomy/scheduling_barrier/flows/clarify.yaml b/decision/taxonomy/scheduling_barrier/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9af0164a47c986b3c15d900d721318aba04b91f7
--- /dev/null
+++ b/decision/taxonomy/scheduling_barrier/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: scheduling_barrier
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: scheduling_barrier_clarify
+      goal: "Ask the patient to clarify what barrier they are experiencing with their care"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "Could you tell me a bit more about what's making it hard to complete your care?"
+      must_not:
+        - "you need to"
+        - "you must"
+      max_questions: 1
+    collects:
+      - scheduling_barrier_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: resource_referral
diff --git a/decision/taxonomy/scheduling_barrier/flows/resource_referral.yaml b/decision/taxonomy/scheduling_barrier/flows/resource_referral.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f43395eba98d17ab5b840f152363d26b63050111
--- /dev/null
+++ b/decision/taxonomy/scheduling_barrier/flows/resource_referral.yaml
@@ -0,0 +1,21 @@
+flow_id: resource_referral
+type: resolution
+domain: scheduling_barrier
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: scheduling_barrier_resource_referral
+      goal: "Connect the patient with appropriate resources for their identified barrier and document the need"
+      tone: warm_professional
+      must_include:
+        - "resources"
+        - "care team"
+      must_not:
+        - "nothing we can do"
+        - "your problem"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/scheduling_barrier/flows/scheduling_assist.yaml b/decision/taxonomy/scheduling_barrier/flows/scheduling_assist.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9045aff2de6c00d4b0c8aecbd8275b927ea15c9c
--- /dev/null
+++ b/decision/taxonomy/scheduling_barrier/flows/scheduling_assist.yaml
@@ -0,0 +1,21 @@
+flow_id: scheduling_assist
+type: resolution
+domain: scheduling_barrier
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: scheduling_barrier_scheduling_assist
+      goal: "Help the patient identify a workable time and note their preferences for the care team to follow up on scheduling"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "nothing we can do"
+        - "that's not possible"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/scheduling_barrier/rules.yaml b/decision/taxonomy/scheduling_barrier/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..956c269676d5de90d140e11712dfde74b77332e5
--- /dev/null
+++ b/decision/taxonomy/scheduling_barrier/rules.yaml
@@ -0,0 +1,21 @@
+domain: scheduling_barrier
+target_risk_class: R0
+
+decision_rules:
+  - id: scheduling_barrier_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: barrier_assessment
+
+  - id: scheduling_barrier_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: barrier_assessment
+
+  - id: scheduling_barrier_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/scheduling_barrier/triggers.yaml b/decision/taxonomy/scheduling_barrier/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4be164a62f8201d461efec343749f678b28bf3d0
--- /dev/null
+++ b/decision/taxonomy/scheduling_barrier/triggers.yaml
@@ -0,0 +1,81 @@
+domain: scheduling_barrier
+priority: 31
+
+lexical_signals:
+  high:
+    phrases:
+      - "can't get there"
+      - "too expensive"
+      - "no ride to the appointment"
+      - "can't take time off work"
+      - "no insurance for that"
+      - "can't afford the copay"
+      - "don't have transportation"
+      - "no way to get to the doctor"
+      - "can't afford the test"
+      - "don't have a car"
+      - "no one to drive me"
+      - "can't miss work for the appointment"
+      - "insurance won't cover it"
+      - "cost is too much"
+      - "can't pay for the visit"
+      - "no bus route to the clinic"
+      - "too far to travel"
+      - "can't get a ride"
+    regex:
+      - "(can't|cannot|unable|no\\s+way).{0,15}(get\\s+there|get\\s+to|make\\s+it|afford|pay)"
+      - "(no|don't\\s+have).{0,15}(ride|transport|car|driver|insurance|money|way\\s+to\\s+get)"
+      - "(too|really).{0,10}(expensive|costly|far|much\\s+money)"
+      - "(can't|cannot).{0,15}(take\\s+time\\s+off|miss\\s+work|leave\\s+work|get\\s+off\\s+work)"
+      - "(insurance|coverage).{0,15}(won't|doesn't|does\\s+not|don't).{0,10}(cover|pay|include)"
+      - "(cost|copay|deductible|bill).{0,10}(too\\s+much|too\\s+high|too\\s+expensive|can't\\s+afford)"
+  medium:
+    phrases:
+      - "transportation issue"
+      - "worried about the cost"
+      - "not sure I can get there"
+      - "schedule conflict"
+      - "hard to get to appointments"
+      - "financial concern about the visit"
+      - "need help with transportation"
+      - "looking for a ride"
+      - "the visit is expensive"
+      - "struggling to afford care"
+      - "work schedule is a problem"
+    partials:
+      - "transportation"
+      - "can't afford"
+      - "no ride"
+      - "too expensive"
+      - "no insurance"
+      - "cost of the"
+      - "can't get there"
+      - "time off work"
+  low:
+    partials:
+      - "cost"
+      - "afford"
+      - "ride"
+      - "transportation"
+      - "insurance"
+      - "too far"
+      - "work schedule"
+
+negation_handling:
+  patterns:
+    - "I can get there"
+    - "I have a ride"
+    - "transportation is not a problem"
+    - "I can afford it"
+    - "insurance covers it"
+    - "cost is fine"
+    - "no trouble getting there"
+    - "I have a way to get there"
+    - "I can take time off"
+    - "my insurance will cover it"
+    - "not worried about cost"
+    - "rides are not an issue"
+    - "getting there is easy"
+    - "I have transportation"
+    - "I can make it"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/screening_gap_identified/flows/clarify.yaml b/decision/taxonomy/screening_gap_identified/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c19b13f022454c9deff171ba8c5a49f3059e032b
--- /dev/null
+++ b/decision/taxonomy/screening_gap_identified/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: screening_gap_identified
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: screening_gap_clarify
+      goal: "Ask patient to describe which screening or preventive care they are asking about"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "cancer"
+      max_questions: 1
+    collects:
+      - screening_gap_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: gap_notification
diff --git a/decision/taxonomy/screening_gap_identified/flows/gap_notification.yaml b/decision/taxonomy/screening_gap_identified/flows/gap_notification.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..381b0339e998e4591ad7cc39d28113badbfea8b6
--- /dev/null
+++ b/decision/taxonomy/screening_gap_identified/flows/gap_notification.yaml
@@ -0,0 +1,52 @@
+flow_id: gap_notification
+type: assessment
+domain: screening_gap_identified
+
+required_slots:
+  - gap_type
+  - last_screening_date
+  - scheduling_preference
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: screening_gap_notify_step1
+      goal: "Identify which screening is overdue and when the patient last had it"
+      tone: supportive_professional
+      must_include:
+        - "important"
+        - "screening"
+      must_ask:
+        - "Which screening are we talking about?"
+        - "Do you remember approximately when you last had this done?"
+      must_not:
+        - "cancer"
+        - "too late"
+        - "dangerous"
+      max_questions: 2
+    collects:
+      - gap_type
+      - last_screening_date
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: screening_gap_notify_step2
+      goal: "Help the patient plan to schedule the screening"
+      tone: supportive_professional
+      must_include:
+        - "schedule"
+      must_ask:
+        - "Would you like help scheduling this screening?"
+      must_not:
+        - "cancer"
+        - "overdue"
+        - "negligent"
+      max_questions: 1
+    collects:
+      - scheduling_preference
+
+exit:
+  on_complete: scheduling_assist
+  on_unclear: scheduling_assist
diff --git a/decision/taxonomy/screening_gap_identified/flows/scheduling_assist.yaml b/decision/taxonomy/screening_gap_identified/flows/scheduling_assist.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d469e2d3bc56ec16bdcb12b764e8a945a1daa5fc
--- /dev/null
+++ b/decision/taxonomy/screening_gap_identified/flows/scheduling_assist.yaml
@@ -0,0 +1,22 @@
+flow_id: scheduling_assist
+type: resolution
+domain: screening_gap_identified
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: screening_gap_schedule_assist
+      goal: "Confirm the screening gap has been noted and inform the patient their care team will help schedule it"
+      tone: supportive_professional
+      must_include:
+        - "care team"
+        - "schedule"
+      must_not:
+        - "cancer"
+        - "too late"
+        - "dangerous"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/screening_gap_identified/rules.yaml b/decision/taxonomy/screening_gap_identified/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..703db1ef4efae1d6deba04fe64f8376007baef35
--- /dev/null
+++ b/decision/taxonomy/screening_gap_identified/rules.yaml
@@ -0,0 +1,21 @@
+domain: screening_gap_identified
+target_risk_class: R0
+
+decision_rules:
+  - id: screening_gap_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: gap_notification
+
+  - id: screening_gap_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: gap_notification
+
+  - id: screening_gap_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/screening_gap_identified/triggers.yaml b/decision/taxonomy/screening_gap_identified/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..25456b70d8187a0edc687c7a3ba1607b6da412d1
--- /dev/null
+++ b/decision/taxonomy/screening_gap_identified/triggers.yaml
@@ -0,0 +1,64 @@
+domain: screening_gap_identified
+priority: 20
+
+lexical_signals:
+  high:
+    phrases:
+      - "overdue for my mammogram"
+      - "haven't had a colonoscopy in years"
+      - "overdue for my screening"
+      - "missed my cancer screening"
+      - "need to schedule my mammogram"
+      - "haven't had my annual screening"
+      - "overdue for a pap smear"
+      - "way past due for colonoscopy"
+      - "skipped my screening last year"
+      - "haven't had a bone density test"
+      - "need to get my colon checked"
+      - "behind on my screenings"
+      - "overdue for my physical"
+    regex:
+      - "(overdue|past\\s+due|behind|late).{0,15}(screening|mammogram|colonoscopy|pap|physical|check.?up)"
+      - "(haven't|have\\s+not|didn't|never).{0,15}(had|done|gotten|scheduled).{0,15}(screening|mammogram|colonoscopy|pap)"
+      - "(missed|skipped|forgot).{0,15}(screening|mammogram|colonoscopy|pap|check.?up|physical)"
+  medium:
+    phrases:
+      - "need to schedule a screening"
+      - "when was my last mammogram"
+      - "colonoscopy question"
+      - "screening reminder"
+      - "due for a check-up"
+      - "need to get screened"
+      - "should I get a mammogram"
+      - "time for my colonoscopy"
+      - "screening appointment"
+      - "preventive care"
+      - "need to schedule a physical"
+    partials:
+      - "mammogram"
+      - "colonoscopy"
+      - "screening"
+      - "pap smear"
+      - "bone density"
+      - "preventive"
+  low:
+    partials:
+      - "check-up"
+      - "overdue"
+      - "annual exam"
+      - "physical exam"
+
+negation_handling:
+  patterns:
+    - "up to date on screenings"
+    - "just had my mammogram"
+    - "colonoscopy was recent"
+    - "all screenings are current"
+    - "had my screening last month"
+    - "not overdue"
+    - "screenings are done"
+    - "everything is up to date"
+    - "just finished my screening"
+    - "already scheduled my mammogram"
+    - "already had my colonoscopy"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/screening_refusal/flows/acknowledge_refusal.yaml b/decision/taxonomy/screening_refusal/flows/acknowledge_refusal.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5ff042774258f894664188fb2a4fbe9823255845
--- /dev/null
+++ b/decision/taxonomy/screening_refusal/flows/acknowledge_refusal.yaml
@@ -0,0 +1,22 @@
+flow_id: acknowledge_refusal
+type: resolution
+domain: screening_refusal
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: screening_refusal_acknowledge
+      goal: "Respect the patient's decision, document the refusal, and let them know they can change their mind"
+      tone: warm_professional
+      must_include:
+        - "respect your decision"
+        - "care team"
+      must_not:
+        - "you should reconsider"
+        - "wrong choice"
+        - "irresponsible"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/screening_refusal/flows/clarify.yaml b/decision/taxonomy/screening_refusal/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..dee33d99ef5a460a8dae9ce67a397a2b2f128763
--- /dev/null
+++ b/decision/taxonomy/screening_refusal/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: screening_refusal
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: screening_refusal_clarify
+      goal: "Ask the patient to clarify whether they are declining a screening or test"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "Could you tell me a bit more about what you mean? Are you thinking about a particular test or screening?"
+      must_not:
+        - "you need to"
+        - "required"
+      max_questions: 1
+    collects:
+      - screening_refusal_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: acknowledge_refusal
diff --git a/decision/taxonomy/screening_refusal/flows/motivational_support.yaml b/decision/taxonomy/screening_refusal/flows/motivational_support.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c92043d0b9ecf9c51996234fed3476863bbb079c
--- /dev/null
+++ b/decision/taxonomy/screening_refusal/flows/motivational_support.yaml
@@ -0,0 +1,54 @@
+flow_id: motivational_support
+type: assessment
+domain: screening_refusal
+
+required_slots:
+  - refusal_reason
+  - screening_type
+  - openness_to_discussion
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: screening_refusal_motivational_step1
+      goal: "Understand why the patient is declining the screening and which screening is involved"
+      tone: respectful_nonjudgmental
+      must_include:
+        - "understand"
+        - "respect"
+      must_ask:
+        - "Can you tell me a bit about why you'd prefer not to do this screening?"
+        - "Which screening or test are we talking about?"
+      must_not:
+        - "you should"
+        - "you have to"
+        - "wrong decision"
+      max_questions: 2
+    collects:
+      - refusal_reason
+      - screening_type
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: screening_refusal_motivational_step2
+      goal: "Explore whether the patient is open to discussing the screening further or receiving more information"
+      tone: respectful_nonjudgmental
+      must_include:
+        - "information"
+      must_ask:
+        - "Would you be open to hearing a little more about what the screening involves, or would you prefer we move on?"
+      must_not:
+        - "you need to"
+        - "you must"
+        - "irresponsible"
+      max_questions: 1
+    collects:
+      - openness_to_discussion
+
+exit:
+  on_complete: evaluate_concern
+  on_concern: acknowledge_refusal
+  on_low_risk: acknowledge_refusal
+  on_unclear: acknowledge_refusal
diff --git a/decision/taxonomy/screening_refusal/rules.yaml b/decision/taxonomy/screening_refusal/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5844895a8d15b9091dc571b0a6ee15243a9b8712
--- /dev/null
+++ b/decision/taxonomy/screening_refusal/rules.yaml
@@ -0,0 +1,21 @@
+domain: screening_refusal
+target_risk_class: R0
+
+decision_rules:
+  - id: screening_refusal_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: motivational_support
+
+  - id: screening_refusal_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: motivational_support
+
+  - id: screening_refusal_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/screening_refusal/triggers.yaml b/decision/taxonomy/screening_refusal/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..25bccd3b740d312ddfba3b6fba9e55584e0936b0
--- /dev/null
+++ b/decision/taxonomy/screening_refusal/triggers.yaml
@@ -0,0 +1,70 @@
+domain: screening_refusal
+priority: 30
+
+lexical_signals:
+  high:
+    phrases:
+      - "don't want the test"
+      - "not interested in the screening"
+      - "refuse the screening"
+      - "I decline the test"
+      - "no thanks to the screening"
+      - "skip the test"
+      - "rather not do the screening"
+      - "don't believe in that test"
+      - "I'm not doing the screening"
+      - "I don't want to be screened"
+      - "not going to do the test"
+      - "I refuse"
+      - "count me out for the screening"
+      - "no screening for me"
+      - "I'll pass on the test"
+      - "don't want any tests"
+    regex:
+      - "(don't|do\\s+not|won't|will\\s+not|refuse|declining|decline)\\s+.{0,15}(test|screen|check|exam)"
+      - "(not\\s+interested|no\\s+thanks|skip|pass\\s+on|opt\\s+out).{0,15}(test|screen|check|exam)"
+      - "(don't|do\\s+not)\\s+believe\\s+in.{0,15}(test|screen|check|exam|mammo|colon)"
+      - "(rather|would\\s+rather)\\s+not.{0,15}(test|screen|check|exam|do\\s+it)"
+  medium:
+    phrases:
+      - "not sure about the test"
+      - "do I really need the screening"
+      - "I don't think I need it"
+      - "can I skip the screening"
+      - "is the test really necessary"
+      - "I heard the test isn't useful"
+      - "not comfortable with the test"
+      - "would rather wait on the screening"
+      - "don't see the point of the test"
+    partials:
+      - "refuse the test"
+      - "skip the screening"
+      - "not interested in screening"
+      - "decline the test"
+      - "opt out"
+      - "don't want screening"
+  low:
+    partials:
+      - "no thanks"
+      - "not interested"
+      - "rather not"
+      - "skip it"
+      - "don't believe in"
+
+negation_handling:
+  patterns:
+    - "I'll do the test"
+    - "go ahead with the screening"
+    - "okay I'll do it"
+    - "ready for the test"
+    - "I want the screening"
+    - "let's do the screening"
+    - "I agree to the test"
+    - "sign me up for the screening"
+    - "I changed my mind about refusing"
+    - "fine I'll do the test"
+    - "willing to do the screening"
+    - "yes to the test"
+    - "I consent to the screening"
+    - "okay let's go ahead"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/seizure/flows/clarify.yaml b/decision/taxonomy/seizure/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..348c7fc3ffcb55f70370efe9f0f9043a8d9e38f3
--- /dev/null
+++ b/decision/taxonomy/seizure/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: seizure
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: seizure_clarify
+      goal: "Ask patient to describe their seizure symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - seizure_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/seizure/flows/escalate_r3.yaml b/decision/taxonomy/seizure/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d995a17ad718853c8dfe40881bbc044d0d6017f1
--- /dev/null
+++ b/decision/taxonomy/seizure/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: seizure
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Inform patient this requires immediate clinical attention and they will be transferred"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/seizure/flows/handoff.yaml b/decision/taxonomy/seizure/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4478dd47279a7275b1b1aa145be4d71ead11a836
--- /dev/null
+++ b/decision/taxonomy/seizure/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: seizure
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: seizure_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: seizure_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/seizure/rules.yaml b/decision/taxonomy/seizure/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..aa7d2ecef680e1eb3ca91be44110d1ddc877db1d
--- /dev/null
+++ b/decision/taxonomy/seizure/rules.yaml
@@ -0,0 +1,21 @@
+domain: seizure
+target_risk_class: R3
+
+decision_rules:
+  - id: seizure_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r3
+
+  - id: seizure_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r3
+
+  - id: seizure_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/seizure/triggers.yaml b/decision/taxonomy/seizure/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..990c726e644d643fd1f7dfae7661748d96e66b01
--- /dev/null
+++ b/decision/taxonomy/seizure/triggers.yaml
@@ -0,0 +1,266 @@
+domain: seizure
+priority: 90
+
+lexical_signals:
+  high:
+    phrases:
+      - "having a seizure"
+      - "convulsions"
+      - "seizure won't stop"
+      - "status epilepticus"
+      - "body shaking uncontrollably"
+      - "grand mal seizure"
+      - "seizing right now"
+      - "had a seizure"
+      - "just had a seizure"
+      - "started shaking on the"
+      - "went stiff and started shaking"
+      - "stiffened and started jerking"
+    regex:
+      - "(having|had|just had)\\s+a\\s+seizure"
+      - "status\\s+epilepticus"
+      - "(body|whole body).{0,10}(shak|jerk|convuls)"
+      - "seizure.{0,15}(just|right now|happened|earlier|today)"
+      - "(went|got|turned)\\s+stiff.{0,20}(shak|jerk|twitch|convuls)"
+      - "(stiffen|stiff).{0,15}(start|began|then).{0,10}(shak|jerk)"
+      - "started\\s+(shaking|jerking|convulsing|seizing)\\s+(on|in|at)"
+      - "(arms?|legs?|limbs?|body).{0,10}(were?|was|are|is)\\s+(jerking|shaking|twitching)"
+      - "stiff.{0,15}(then|and).{0,10}(jerk|shak|twitch)"
+      - "(staring|stared).{0,20}(stiff|rigid|jerk|shak|then)"
+  medium:
+    phrases:
+      - "started seizing"
+      - "seizure just happened"
+      - "body jerking"
+      - "convulsed earlier"
+      - "new seizure activity"
+      - "blanked out"
+      - "blacked out and fell"
+      - "on the floor and don't remember"
+      - "dropped to the ground"
+      - "fell and was shaking"
+      - "lost consciousness"
+      - "passed out and was shaking"
+      - "eyes rolled back"
+      - "think I had a seizure"
+      - "I think I had like a seizure"
+      - "tongue hurts"
+      - "missing a piece of time"
+      - "lost time"
+      - "blank spot"
+      - "wet myself"
+      - "staring then stiff then jerking"
+      - "staring first then stiff"
+      # --- from missed scenarios analysis ---
+      - "started shaking"
+      - "was shaking"
+      - "shaking real bad"
+      - "shaking really bad"
+      - "had some kind of fit"
+      - "had a fit"
+      - "had what I think was a seizure"
+      - "whole body was moving"
+      - "whole body was shaking"
+      - "wasn't responding"
+      - "wouldn't wake up"
+      # --- MINIMIZER coverage ---
+      - "had this weird episode"
+      - "body did this weird thing"
+      - "zoned out for a while"
+      - "lost a chunk of time"
+      - "don't remember the last few minutes"
+      - "tongue is sore and I don't know why"
+      # --- witness/caregiver report ---
+      - "another episode"
+      - "it happened again"
+      - "keeps happening"
+      - "they keep coming"
+      - "won't stop shaking"
+      - "still shaking"
+      - "found them on the floor shaking"
+      - "found him on the floor"
+      - "found her on the floor"
+      - "saw them shaking"
+      - "watched them collapse"
+      - "I saw him shaking"
+      - "I saw her shaking"
+      - "saw him collapse"
+      - "saw her collapse"
+      - "watched him shaking"
+      - "watched her shaking"
+      # --- post-ictal confusion ---
+      - "came to on the floor"
+      - "came to confused"
+      - "came to and felt confused"
+      - "woke up on the floor"
+      - "woke up confused"
+      - "doesn't remember what happened"
+      - "doesn't remember it"
+      - "doesn't remember anything"
+      - "doesn't remember the seizure"
+      - "don't remember what happened"
+      - "don't remember it happening"
+      # --- subtle seizure types / staring spells ---
+      - "staring spell"
+      - "staring spells"
+      - "just staring"
+      - "staring and not responding"
+      - "staring blankly"
+      - "blank stare"
+      - "staring and mumbling"
+      - "staring and making"
+      # --- aura descriptions ---
+      - "metallic taste"
+      - "burnt smell"
+      - "burnt toast smell"
+      - "weird smell before"
+      - "strange smell then"
+      - "deja vu then"
+      - "deja vu and"
+      - "rising feeling"
+      - "rising sensation"
+      - "weird rising sensation"
+      # --- first seizure / new seizure ---
+      - "first seizure"
+      - "first time seizure"
+      - "never had a seizure before"
+      - "new seizure"
+      - "like a seizure"
+      # --- duration concerns ---
+      - "keeps seizing"
+      - "seizures keep coming"
+      - "won't stop seizing"
+      - "multiple seizures"
+    regex:
+      - "(blank|black)ed\\s*(out)?"
+      - "(wet|peed|urinat|soiled).{0,15}(myself|self|pants|clothes)"
+      - "(fell|drop|collaps).{0,20}(floor|ground|down).{0,30}(shak|jerk|don't remember|no memory|can't remember)"
+      - "(shak|jerk|twitch).{0,20}(floor|ground|fell|drop)"
+      - "was\\s+on\\s+the\\s+floor"
+      - "then\\s+I\\s+was\\s+on\\s+the\\s+floor"
+      - "(eyes|eye)\\s+roll"
+      - "lost\\s+consciousness"
+      - "(bit|chew|hurt).{0,10}(tongue|cheek)"
+      - "missing.{0,10}(time|piece|chunk|gap|memory)"
+      - "lost\\s+time"
+      - "(blank|gap|hole)\\s+(spot|in my|in time)"
+      - "(shaking|jerking).{0,20}(on the|on his|on her|on their).{0,10}(floor|couch|ground|bed)"
+      - "(floor|ground).{0,20}(shaking|jerking|stiff|rigid)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(weird|strange).{0,10}(episode|spell|moment|thing).{0,15}(happened|had|earlier|today)"
+      - "(zoned|spaced|phased)\\s+out"
+      - "(don'?t|can'?t|couldn'?t)\\s+remember.{0,15}(how|what|getting|the last|anything|where|why)"
+      - "(shak|trembl|jerk|twitch).{0,20}(a bit|a little|kind of|slightly|for a (minute|moment|second))"
+      - "woke\\s+up.{0,15}(confused|don'?t know|didn'?t know|on the|somewhere)"
+      - "(gap|hole|blank|missing).{0,15}(in my|in time|memory|minutes|moment)"
+      - "body\\s+(did|does|doing).{0,10}(this|a|something).{0,10}(weird|strange|funny)"
+      # --- from missed scenarios analysis ---
+      - "started\\s+shaking"
+      - "(shaking|shook|shook)\\s+(real|really)\\s+bad"
+      - "(some\\s+kind\\s+of|had\\s+a)\\s+(fit|episode|spell|seizure|convulsion)"
+      - "(whole\\s+body|entire\\s+body).{0,15}(moving|shaking|jerking|convulsing|trembling)"
+      - "(wasn'?t|not|wouldn'?t)\\s+(respond|responding|waking|wake|answer)"
+      - "(he|she|my).{0,20}(just\\s+had|had\\s+what).{0,10}(seizure|fit|episode|convulsion)"
+      # --- witness/caregiver report ---
+      - "(saw|found|watched)\\s+(him|her|them|my)\\s+(collapse|shaking|jerking|convulsing|seizing)"
+      - "I\\s+saw\\s+(him|her|them)\\s+(shak|jerk|collaps|convuls|seiz)"
+      - "(heard|saw)\\s+a\\s+thump.{0,20}(found|floor)"
+      # --- post-ictal confusion ---
+      - "(woke up|came to)\\s+(confused|sore|hurting|on the floor|don'?t know)"
+      - "came\\s+to.{0,20}(floor|confused|didn'?t know|disoriented)"
+      - "doesn'?t\\s+remember.{0,20}(it|what|the seizure|anything|happening)"
+      - "don'?t\\s+remember.{0,20}(it happening|what happened|anything)"
+      # --- subtle seizure types / staring ---
+      - "(staring|stared).{0,15}(blankly|and (not|wasn'?t) respond|mumbl|mak)"
+      - "just\\s+(staring|sat there|stood there).{0,15}(not respond|wasn'?t|wouldn'?t)"
+      # --- aura patterns ---
+      - "(metallic|strange|weird|burnt)\\s+(taste|smell).{0,20}(then|before|and)"
+      - "deja\\s+vu.{0,15}(then|and|before|nausea)"
+      - "rising\\s+(feeling|sensation).{0,15}(stomach|then|and)"
+      # --- first/new seizure ---
+      - "(first|new)\\s+(time\\s+)?seizure"
+      - "never\\s+(had|experienced).{0,10}(a\\s+)?seizure"
+      - "(look|looked)\\s+like\\s+a\\s+seizure"
+  low:
+    partials:
+      - "seizure"
+      - "convulsion"
+      - "epileptic"
+      - "twitching"
+      - "weird feeling before I lose"
+      - "smell something strange then"
+      - "brief episode"
+      - "another episode"
+
+negation_handling:
+  patterns:
+    - "no seizures"
+    - "no seizure"
+    - "seizure free"
+    - "no convulsions"
+    - "didn't have a seizure"
+    - "haven't had any seizures"
+    - "haven't had seizures"
+    - "no shaking"
+    - "no jerking"
+    # --- R1 denial coverage ---
+    - "haven't blacked out"
+    - "didn't black out"
+    - "no blackouts"
+    - "haven't blanked out"
+    - "didn't blank out"
+    - "haven't lost consciousness"
+    - "didn't lose consciousness"
+    - "no loss of consciousness"
+    - "haven't lost any time"
+    - "haven't lost time"
+    - "no episodes"
+    - "haven't had any episodes"
+    - "haven't had a seizure"
+    - "no seizure activity"
+    - "haven't fainted or blacked out"
+    - "haven't been confused"
+    - "no confusion or anything"
+    # --- instruction/medication memory context (R1 scenarios) ---
+    - "remember the dosage"
+    - "remember what the doctor"
+    - "remember what to take"
+    - "remember the instructions"
+    - "remember the schedule"
+    - "remember which pill"
+    - "remember which medication"
+    - "remember what I was told"
+    - "remember what my"
+    - "remember if I"
+    - "pharmacy label"
+    - "prescription says"
+    - "label says"
+    - "medication question"
+    - "medication schedule"
+    - "dosing schedule"
+    - "asking about my"
+    - "question about my"
+    - "refill"
+    # --- administrative / routine context suppression ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "when can I come in"
+    - "need a refill"
+    - "routine check"
+    - "just a question"
+    # --- incontinence context (R1 post_procedure_incontinence) ---
+    - "incontinence"
+    - "urine leakage"
+    - "leaking urine"
+    - "bladder control"
+    - "bladder surgery"
+    - "prostate surgery"
+    - "prostate procedure"
+    - "pelvic floor"
+    - "wearing pads"
+    - "since the procedure"
+    - "since surgery"
+    - "since the surgery"
+    - "catheter"
+    - "appointment timing"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/severe_abdominal_pain/flows/clarify.yaml b/decision/taxonomy/severe_abdominal_pain/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8dfc648fa0222b25d398da3a2158e1def90008de
--- /dev/null
+++ b/decision/taxonomy/severe_abdominal_pain/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: severe_abdominal_pain
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: severe_abdominal_pain_clarify
+      goal: "Ask patient to describe their severe abdominal pain symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - severe_abdominal_pain_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/severe_abdominal_pain/flows/escalate_r2.yaml b/decision/taxonomy/severe_abdominal_pain/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d8a2729ef3ec2bd3ca1b6f476249089b4cd69ce2
--- /dev/null
+++ b/decision/taxonomy/severe_abdominal_pain/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: severe_abdominal_pain
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/severe_abdominal_pain/flows/handoff.yaml b/decision/taxonomy/severe_abdominal_pain/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..57a56295aabd84efbec43a74cd8599a0029a5ecc
--- /dev/null
+++ b/decision/taxonomy/severe_abdominal_pain/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: severe_abdominal_pain
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: severe_abdominal_pain_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: severe_abdominal_pain_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/severe_abdominal_pain/flows/safety_screen.yaml b/decision/taxonomy/severe_abdominal_pain/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..43eafaff9d97eb0546ca273eece3fd923bf00fae
--- /dev/null
+++ b/decision/taxonomy/severe_abdominal_pain/flows/safety_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: safety_screen
+type: screening
+domain: severe_abdominal_pain
+
+required_slots:
+  - pain_location
+  - pain_onset
+  - pain_severity
+  - associated_symptoms
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "pain location"
+        - "pain onset"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - pain_location
+      - pain_onset
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "pain severity"
+        - "associated symptoms"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - pain_severity
+      - associated_symptoms
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/decision/taxonomy/severe_abdominal_pain/rules.yaml b/decision/taxonomy/severe_abdominal_pain/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..804c41d114864aa129606a33ceba178d5e99e63f
--- /dev/null
+++ b/decision/taxonomy/severe_abdominal_pain/rules.yaml
@@ -0,0 +1,27 @@
+domain: severe_abdominal_pain
+target_risk_class: R2
+
+decision_rules:
+  - id: severe_abdominal_pain_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: severe_abdominal_pain_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: severe_abdominal_pain_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: severe_abdominal_pain_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/severe_abdominal_pain/triggers.yaml b/decision/taxonomy/severe_abdominal_pain/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0ddb90caaa519d5427e26414aea9e11d641d053b
--- /dev/null
+++ b/decision/taxonomy/severe_abdominal_pain/triggers.yaml
@@ -0,0 +1,171 @@
+domain: severe_abdominal_pain
+priority: 78
+
+lexical_signals:
+  high:
+    phrases:
+      # --- ORIGINAL ---
+      - "severe abdominal pain"
+      - "stomach pain is unbearable"
+      - "worst belly pain"
+      - "abdomen is rigid"
+      - "severe cramping in my stomach"
+      - "acute abdominal pain"
+      # --- EXPANDED naturalistic ---
+      - "belly hurts so bad I can't move"
+      - "doubled over in pain"
+      - "can't stand up straight from the pain"
+      - "worst stomach pain I've ever had"
+      - "worst stomach pain of my life"
+      - "stomach pain is a 10 out of 10"
+      - "stomach pain is excruciating"
+      - "pain in my gut is unbearable"
+      - "abdominal pain and I can't move"
+      - "pain so bad I'm screaming"
+      - "sharp stabbing pain in my stomach"
+      - "my stomach feels like it's ripping apart"
+      - "abdominal pain is getting much worse"
+      - "stomach hurts so bad I'm crying"
+      - "my belly is so tender I can't touch it"
+      - "abdomen is hard and painful"
+      - "stomach pain and I feel like I'm going to pass out"
+    regex:
+      # --- ORIGINAL ---
+      - "severe\\s+(abdominal|stomach|belly)\\s+pain"
+      # --- EXPANDED ---
+      - "(stomach|belly|abdom|gut).{0,15}(unbearable|excruciating|worst|terrible|horrible|agonizing|10\\s+out\\s+of|10/10)"
+      - "(doubled|bent|hunched|curled)\\s+(over|up)\\s+(in|with|from)\\s+(the\\s+)?pain"
+      - "(can'?t|cannot|unable\\s+to)\\s+(stand|sit|move|walk|straighten|get\\s+up).{0,15}(pain|hurt|stomach|belly)"
+      - "pain.{0,15}(so\\s+bad|so\\s+intense|so\\s+severe).{0,20}(scream|cry|throw\\s+up|can'?t)"
+      - "(sharp|stabbing|tearing|ripping|knife).{0,10}(pain|feeling).{0,15}(stomach|belly|abdom|gut|side)"
+      - "(stomach|belly|abdom).{0,10}(feels?|is)\\s+(like\\s+)?(ripping|tearing|on\\s+fire|being\\s+stabbed)"
+      - "(stomach|belly|abdom).{0,15}(rigid|hard|distended|swollen).{0,15}(and\\s+)?pain"
+      - "(worst|most\\s+intense|most\\s+severe).{0,10}(stomach|belly|abdom|gut)\\s+pain"
+      - "(stomach|belly|abdom|gut)\\s+pain.{0,15}(pass\\s+out|faint|vomit|throw\\s+up)"
+      - "(tender|can'?t\\s+touch).{0,15}(stomach|belly|abdom)"
+  medium:
+    phrases:
+      # --- ORIGINAL ---
+      - "bad stomach pain"
+      - "really hurts in my belly"
+      - "abdominal pain getting worse"
+      - "constant stomach pain"
+      - "sharp pain in abdomen"
+      - "stomach pain won't go away"
+      # --- EXPANDED naturalistic ---
+      - "pain in my gut"
+      - "stomach is killing me"
+      - "belly is really hurting"
+      - "my stomach won't stop cramping"
+      - "cramping really bad"
+      - "sharp abdominal pain"
+      - "stomach pain since I got home"
+      - "stomach pain that comes and goes but it's bad"
+      - "woke up with terrible stomach pain"
+      - "pain all across my abdomen"
+      - "lower belly pain"
+      - "upper stomach pain"
+      - "pain on the right side of my belly"
+      - "pain on the left side of my belly"
+      - "stomach cramps are getting worse"
+      - "burning pain in my stomach"
+      - "deep ache in my belly"
+      - "feels like something is wrong in my stomach"
+      - "stomach pain after eating"
+      - "stomach hurts really bad"
+      - "belly is in a lot of pain"
+      - "gut feels like it's on fire"
+      - "throbbing pain in my abdomen"
+      - "nausea and bad stomach pain"
+      - "stomach pain and vomiting"
+      # --- additional patterns ---
+      - "guarding my belly"
+      - "can't let anyone touch my stomach"
+      - "pain is worse when I move"
+      - "every bump in the road makes it worse"
+    regex:
+      # --- EXPANDED ---
+      - "(stomach|belly|gut|abdom).{0,10}(is\\s+)?(killing|destroying|wrecking)\\s+(me|him|her)"
+      - "(stomach|belly|abdom|gut).{0,10}(really|very|so|super)\\s+(hurt|pain|sore|tender)"
+      - "(stomach|belly|abdom)\\s+(won'?t|doesn'?t)\\s+stop\\s+(cramp|hurt|ach)"
+      - "(cramp|spasm).{0,10}(really|very|so|pretty)\\s+bad"
+      - "(sharp|burning|throbbing|deep|dull).{0,10}(pain|ache).{0,15}(stomach|belly|abdom|gut|side)"
+      - "(pain|ache|hurt).{0,10}(in|across|all\\s+over)\\s+(my\\s+)?(abdom|stomach|belly|gut)"
+      - "(woke\\s+up|came\\s+on|started).{0,15}(terrible|bad|awful|horrible)\\s+(stomach|belly|abdom)\\s+pain"
+      - "(stomach|belly|abdom)\\s+pain.{0,15}(worse|worsening|increasing|intensif)"
+      - "(lower|upper|right|left).{0,10}(stomach|belly|abdom|side)\\s+(pain|hurt|ache|cramp)"
+      - "(nausea|vomit|throw).{0,20}(stomach|belly|abdom)\\s+(pain|hurt|ache)"
+      - "(stomach|belly|abdom)\\s+(pain|hurt|ache).{0,20}(nausea|vomit|throw)"
+      - "(feels?|something).{0,10}(wrong|off).{0,10}(stomach|belly|gut|abdom|inside)"
+      - "(belly|stomach|abdom).{0,15}(pain|hurt|ache).{0,20}(wave|comes\\s+and\\s+goes|spike|intense)"
+      - "(curl|curled)\\s+(up|into).{0,15}(pain|stomach|belly)"
+      - "(threw|throw)\\s+up.{0,20}(stomach|belly|abdom|pain)"
+    partials:
+      - "stomach killing me"
+      - "gut pain"
+      - "side pain"
+      - "cramping bad"
+      - "belly cramping"
+  low:
+    partials:
+      # --- ORIGINAL ---
+      - "stomach hurts"
+      - "belly pain"
+      - "abdominal discomfort"
+      # --- EXPANDED ---
+      - "stomach pain"
+      - "stomach ache"
+      - "stomachache"
+      - "abdominal pain"
+      - "gut hurts"
+      - "belly hurts"
+      - "tummy pain"
+      - "tummy ache"
+      - "cramping"
+      - "abdominal cramps"
+      - "stomach cramps"
+      - "stomach tender"
+      - "belly sore"
+      - "epigastric"
+      - "periumbilical"
+      - "flank pain"
+
+negation_handling:
+  patterns:
+    # --- ORIGINAL ---
+    - "no abdominal pain"
+    - "stomach feels fine"
+    - "belly pain is gone"
+    # --- EXPANDED ---
+    - "no stomach pain"
+    - "no belly pain"
+    - "abdominal pain resolved"
+    - "stomach pain resolved"
+    - "stomach pain went away"
+    - "stomach pain is better"
+    - "stomach pain is improving"
+    - "belly pain getting better"
+    - "pain is manageable"
+    - "abdominal pain much better"
+    - "stomach doesn't hurt anymore"
+    - "belly is fine now"
+    - "no more cramping"
+    - "cramps have stopped"
+    - "stomach feels okay"
+    - "stomach feels normal"
+    - "abdominal pain is gone"
+    - "pain went away on its own"
+    - "pain is mild"
+    - "just a little sore"
+    - "only hurts when I press on it"
+    - "only tender to touch"
+    - "mild discomfort"
+    - "stomach is settling down"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/severe_bleeding/flows/clarify.yaml b/decision/taxonomy/severe_bleeding/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ab5385d0ac8bbea5434bcd1434b52af856f42f1d
--- /dev/null
+++ b/decision/taxonomy/severe_bleeding/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: severe_bleeding
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: severe_bleeding_clarify
+      goal: "Ask patient to describe their severe bleeding symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - severe_bleeding_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/severe_bleeding/flows/escalate_r3.yaml b/decision/taxonomy/severe_bleeding/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..964fdda9295547233cba076a8e5faee543b49d36
--- /dev/null
+++ b/decision/taxonomy/severe_bleeding/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: severe_bleeding
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Inform patient this requires immediate clinical attention and they will be transferred"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/severe_bleeding/flows/handoff.yaml b/decision/taxonomy/severe_bleeding/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b4bebc55d92662bb365493444d106a7b1b6f08ba
--- /dev/null
+++ b/decision/taxonomy/severe_bleeding/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: severe_bleeding
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: severe_bleeding_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: severe_bleeding_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/severe_bleeding/rules.yaml b/decision/taxonomy/severe_bleeding/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..969b81cc35c632bbd72eb598262b6416e2f920e6
--- /dev/null
+++ b/decision/taxonomy/severe_bleeding/rules.yaml
@@ -0,0 +1,21 @@
+domain: severe_bleeding
+target_risk_class: R3
+
+decision_rules:
+  - id: severe_bleeding_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r3
+
+  - id: severe_bleeding_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r3
+
+  - id: severe_bleeding_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/severe_bleeding/triggers.yaml b/decision/taxonomy/severe_bleeding/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..45e14fb9c8f4ecb55118f3115d3247d200321859
--- /dev/null
+++ b/decision/taxonomy/severe_bleeding/triggers.yaml
@@ -0,0 +1,102 @@
+domain: severe_bleeding
+priority: 96
+
+lexical_signals:
+  high:
+    phrases:
+      - "won't stop bleeding"
+      - "bleeding heavily"
+      - "blood soaking through"
+      - "hemorrhaging"
+      - "spurting blood"
+      - "can't control the bleeding"
+      - "bleeding profusely"
+      - "blood everywhere"
+      - "bleeding through the bandage"
+      - "blood is pouring out"
+      - "soaked through the gauze"
+      - "massive bleeding"
+      - "lost a lot of blood"
+      - "bleeding really bad"
+      - "blood won't stop coming"
+      - "gushing blood"
+    regex:
+      - "(won'?t|can'?t)\\s+stop\\s+bleeding"
+      - "hemorrhag"
+      - "bleed(ing)?\\s+(heavy|heav|bad|profuse|a\\s+lot|really|so\\s+much|through|massive)"
+      - "a lot of\\s+bleed"
+      - "(soak|soaked|soaking)\\s+(through|the)"
+      - "blood\\s+(everywhere|pouring|gushing|won'?t)"
+      - "bleed(ing)?.{0,15}(not|isn'?t|won'?t).{0,10}(stop|slow|let|clot)"
+      # --- caregiver/indirect ---
+      - "(so much|all this|too much)\\s+blood"
+      # --- quantity indicators ---
+      - "(pooling|pool of)\\s+blood"
+      - "blood\\s+(pooling|collecting|accumulating)"
+      - "(drenched|saturated|sopping)\\s+(in|with)\\s+blood"
+      # --- visual severity ---
+      - "blood\\s+(spurting|squirting|shooting)"
+      - "(arterial|pulsing|pulsating)\\s+bleed"
+      # --- caregiver reports ---
+      - "(he|she|they|my (husband|wife|child|kid|mom|dad|son|daughter))('s|\\s+is)?\\s+bleeding\\s+(bad|heavy|a lot|so much|profuse)"
+      - "there('s|\\s+is)\\s+(so much|a lot of|too much)\\s+blood"
+      # --- location + severity ---
+      - "(head|scalp|face)\\s+(wound|cut|gash).{0,20}(bleed|blood)"
+      - "(deep|large|bad)\\s+(cut|gash|laceration).{0,20}(bleed|blood|won'?t stop)"
+  medium:
+    phrases:
+      - "a lot of blood"
+      - "bleeding from incision"
+      - "wound is bleeding again"
+      - "blood coming through bandage"
+      - "continuous bleeding"
+      - "blood won't clot"
+      - "still bleeding"
+      - "incision is oozing"
+      - "bleeding from the surgical site"
+      - "blood on my clothes"
+      - "dripping blood"
+      - "bleeding more than before"
+      - "there's blood"
+      - "a fair amount of bleeding"
+      - "bright red bleeding"
+      - "enough to drip"
+      - "nose and mouth are bleeding"
+      - "cut and it's bleeding"
+      - "a lot of bleeding"
+      - "bright red blood"
+      - "blood in the toilet"
+      - "blood on the floor"
+      - "bleeding from my rectum"
+      - "bleeding from my butt"
+      - "way more than normal"
+    regex:
+      - "(blood|bleed).{0,20}(a lot|fair amount|quite a bit|drip|splash|bright red)"
+      - "bright\\s+red\\s+(blood|bleed)"
+      - "(nose|mouth|gums|ear|rectum|rectal|butt|bottom|vagina|vaginal).{0,15}(bleed|blood)"
+      - "bleed(ing)?\\s+(from|out of)\\s+(my\\s+)?(rectum|butt|bottom|nose|mouth|ear|gums|vagina|incision|cut|wound)"
+      - "(cut|wound|incision|lacerat).{0,35}(bleed|blood)"
+      - "blood\\s+(in|all over)\\s+(the\\s+)?(toilet|bowl|water|sink|tub|floor)"
+      - "a lot of.{0,15}blood"
+      - "bleed(ing)?\\s+a\\s+(bit|little).{0,30}(not|isn'?t|won'?t).{0,10}(stop|slow|clot)"
+  low:
+    partials:
+      - "bleeding"
+      - "blood loss"
+      - "hemorrhage"
+      - "a lot of blood"
+
+negation_handling:
+  patterns:
+    - "bleeding stopped"
+    - "no more bleeding"
+    - "bleeding is controlled"
+    # --- administrative / routine context suppression ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "when can I come in"
+    - "medication refill"
+    - "need a refill"
+    - "routine check"
+    - "just a question"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/severe_diarrhea/flows/clarify.yaml b/decision/taxonomy/severe_diarrhea/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0eb33b16c5365ca0f835b5929f56e7ccb1c30c27
--- /dev/null
+++ b/decision/taxonomy/severe_diarrhea/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: severe_diarrhea
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: severe_diarrhea_clarify
+      goal: "Ask patient to describe their severe diarrhea symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - severe_diarrhea_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/severe_diarrhea/flows/escalate_r2.yaml b/decision/taxonomy/severe_diarrhea/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b9771d3a0bfcc4f98772210287db59f97557d6b5
--- /dev/null
+++ b/decision/taxonomy/severe_diarrhea/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: severe_diarrhea
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/severe_diarrhea/flows/handoff.yaml b/decision/taxonomy/severe_diarrhea/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d8b5f6efc3a5357c813f882305fa3b42a787b363
--- /dev/null
+++ b/decision/taxonomy/severe_diarrhea/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: severe_diarrhea
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: severe_diarrhea_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: severe_diarrhea_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/severe_diarrhea/flows/safety_screen.yaml b/decision/taxonomy/severe_diarrhea/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1fe73098f29a8395189d04df6b9dbe79547da7f9
--- /dev/null
+++ b/decision/taxonomy/severe_diarrhea/flows/safety_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: safety_screen
+type: screening
+domain: severe_diarrhea
+
+required_slots:
+  - diarrhea_frequency
+  - duration
+  - fluid_intake
+  - dehydration_signs
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "diarrhea frequency"
+        - "duration"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - diarrhea_frequency
+      - duration
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "fluid intake"
+        - "dehydration signs"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - fluid_intake
+      - dehydration_signs
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/decision/taxonomy/severe_diarrhea/rules.yaml b/decision/taxonomy/severe_diarrhea/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d6fcce3e47d0de87842d56ad6241fbe84eb1febb
--- /dev/null
+++ b/decision/taxonomy/severe_diarrhea/rules.yaml
@@ -0,0 +1,27 @@
+domain: severe_diarrhea
+target_risk_class: R2
+
+decision_rules:
+  - id: severe_diarrhea_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: severe_diarrhea_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: severe_diarrhea_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: severe_diarrhea_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/severe_diarrhea/triggers.yaml b/decision/taxonomy/severe_diarrhea/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..098be4551815904951ec471b0f6f1992c9c3f81d
--- /dev/null
+++ b/decision/taxonomy/severe_diarrhea/triggers.yaml
@@ -0,0 +1,186 @@
+domain: severe_diarrhea
+priority: 65
+
+lexical_signals:
+  high:
+    phrases:
+      # --- ORIGINAL ---
+      - "diarrhea won't stop and I'm dehydrated"
+      - "severe diarrhea and can't keep fluids down"
+      - "watery diarrhea all day and feeling faint"
+      - "diarrhea 10 times today"
+      - "C. diff symptoms"
+      - "severe diarrhea since discharge"
+      # --- EXPANDED naturalistic ---
+      - "can't leave the bathroom"
+      - "running to the bathroom every few minutes"
+      - "I'm on the toilet constantly"
+      - "diarrhea won't stop"
+      - "going every 20 minutes"
+      - "going every 30 minutes"
+      - "liquid coming out of me nonstop"
+      - "diarrhea and I can't keep anything down"
+      - "watery diarrhea with blood"
+      - "diarrhea and I feel like I'm going to pass out"
+      - "I've had diarrhea all day and I'm getting weak"
+      - "I've lost count of how many times I've gone"
+      - "can't make it to the bathroom in time"
+      - "having accidents because the diarrhea is so bad"
+      - "stomach is emptying and it won't stop"
+      - "nothing but water coming out"
+      - "diarrhea more than 10 times"
+      - "watery diarrhea since I got home from the hospital"
+    regex:
+      # --- ORIGINAL ---
+      - "severe\\s+diarrhea"
+      - "diarrhea.*(dehydrat|faint|can'?t\\s+keep)"
+      # --- EXPANDED ---
+      - "(can'?t|cannot)\\s+(leave|get\\s+off|get\\s+away\\s+from)\\s+(the\\s+)?(bathroom|toilet)"
+      - "(running|rushing|going)\\s+(to|back\\s+to)\\s+(the\\s+)?(bathroom|toilet)"
+      - "(on\\s+the\\s+toilet|in\\s+the\\s+bathroom)\\s+(all\\s+day|constantly|nonstop|non-stop|every)"
+      - "(going|diarrhea|runs).{0,15}every\\s+\\d+\\s+(minutes?|mins?|hours?|hrs?)"
+      - "(diarrhea|stool|bowel).{0,15}(won'?t|doesn'?t|will\\s+not)\\s+stop"
+      - "(liquid|watery|water)\\s+(stool|coming\\s+out|diarrhea|bowel)"
+      - "(can'?t|cannot)\\s+(make\\s+it|get|be\\s+away)\\s+(to|from)\\s+(the\\s+)?(bathroom|toilet)"
+      - "(accident|soil|mess).{0,20}(diarrhea|bowel|bathroom|can'?t\\s+make)"
+      - "diarrhea.{0,20}(blood|bloody|red|black|tarry)"
+      - "(\\d{2,}|ten|twelve|fifteen|twenty)\\s+(times?|episodes?|bouts?|trips?)"
+      - "lost\\s+count.{0,15}(times|how\\s+many|bathroom|gone)"
+      - "nothing\\s+but\\s+(water|liquid)\\s+(coming|is\\s+coming)\\s+out"
+      - "(explosive|uncontrollable|non-?stop|nonstop)\\s+(diarrhea|bowel|stool)"
+  medium:
+    phrases:
+      # --- ORIGINAL ---
+      - "diarrhea and feeling dehydrated"
+      - "loose stools many times a day"
+      - "can't stop having diarrhea"
+      - "diarrhea since discharge"
+      - "watery diarrhea and weak"
+      - "diarrhea with cramping"
+      # --- EXPANDED naturalistic ---
+      - "running to the bathroom"
+      - "watery diarrhea"
+      - "liquid stool"
+      - "diarrhea keeps coming back"
+      - "still having diarrhea"
+      - "diarrhea is getting worse"
+      - "stomach is just gurgling and everything comes out liquid"
+      - "going to the bathroom a lot more than normal"
+      - "bowels are all messed up since I got home"
+      - "can't eat anything without getting diarrhea"
+      - "loose stools with cramping"
+      - "diarrhea and stomach cramps"
+      - "diarrhea with nausea"
+      - "I keep having the runs"
+      - "stools are completely liquid"
+      - "diarrhea and feel really weak"
+      - "been going to the bathroom nonstop"
+      - "my gut is a mess"
+      - "the antibiotic is giving me bad diarrhea"
+      - "started having diarrhea after I started the new medication"
+      - "diarrhea and my stomach won't stop cramping"
+      # --- MINIMIZER coverage ---
+      - "just a bit of an upset stomach"
+      - "probably something I ate"
+      - "it's not that bad, just going a bit more than usual"
+      - "stomach is just a little off"
+      - "bowels are just a bit loose"
+      - "just have the runs, probably nothing"
+      - "a little diarrhea but I'm managing"
+      - "stomach has been kind of funny"
+      - "going to the bathroom more than normal"
+      - "stools are a bit looser than usual"
+      # --- additional dehydration signals ---
+      - "dizzy from the diarrhea"
+      - "lips are dry and I keep going"
+      - "haven't been able to drink enough"
+    regex:
+      # --- EXPANDED ---
+      - "(watery|liquid|loose|runny)\\s+(stool|bowel|diarrhea|poop|movement)"
+      - "diarrhea.{0,20}(worse|getting\\s+worse|increasing|more\\s+frequent)"
+      - "diarrhea.{0,20}(cramp|nausea|vomit|weak|pain)"
+      - "(can'?t|cannot)\\s+eat.{0,15}(without|diarrhea|get)"
+      - "(the\\s+)?(runs|trots)\\s+(won'?t|keep|all\\s+day)"
+      - "(keep|keeps|kept)\\s+(having|getting)\\s+(the\\s+)?(runs|diarrhea|loose\\s+stool)"
+      - "(gut|bowel|stomach|belly).{0,10}(mess|messed|torn\\s+up|tore\\s+up)"
+      - "(antibiotic|medication|medicine|drug).{0,20}diarrhea"
+      - "diarrhea.{0,20}(antibiotic|medication|medicine|new\\s+med)"
+      - "(stool|bowel\\s+movement).{0,10}(completely|all|just|nothing\\s+but)\\s+(liquid|water)"
+      - "bathroom\\s+(nonstop|non-?stop|all\\s+day|all\\s+night|constantly)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(just|only).{0,10}(a\\s+)?(little|bit|touch).{0,10}(diarrhea|loose|upset|off|funny|runny)"
+      - "(probably|might be).{0,10}(just|nothing|something I ate|food|bug).{0,15}(diarrhea|stomach|bowel|loose)"
+      - "(stomach|bowel|gut|tummy).{0,10}(a\\s+)?(bit|little|kind of|sort of).{0,10}(off|upset|funny|loose|messed|dodgy)"
+      - "(going|bathroom|toilet).{0,15}(more|a lot|a bit more|more often).{0,10}(than usual|than normal|lately|today)"
+      - "(stool|bowel).{0,10}(a\\s+)?(bit|little|kind of).{0,10}(loose|watery|runny|soft)"
+    partials:
+      - "the runs"
+      - "running to the bathroom"
+      - "stomach bug"
+      - "loose bowels"
+      - "bowel problems"
+  low:
+    partials:
+      # --- ORIGINAL ---
+      - "diarrhea"
+      - "loose stools"
+      - "watery stool"
+      # --- EXPANDED ---
+      - "loose bowel"
+      - "frequent stools"
+      - "liquid stool"
+      - "the runs"
+      - "upset stomach"
+      - "bowel issues"
+      - "going a lot"
+      - "runny stool"
+      - "C. diff"
+      - "cdiff"
+      - "clostridium"
+      - "colitis"
+      - "GI issues"
+
+negation_handling:
+  patterns:
+    # --- ORIGINAL ---
+    - "diarrhea stopped"
+    - "stools normalizing"
+    - "no diarrhea"
+    # --- EXPANDED ---
+    - "diarrhea resolved"
+    - "diarrhea is better"
+    - "diarrhea is improving"
+    - "stools are firming up"
+    - "stools are more formed"
+    - "bowels are back to normal"
+    - "bowel movements are normal"
+    - "diarrhea went away"
+    - "no more diarrhea"
+    - "no loose stools"
+    - "not having diarrhea anymore"
+    - "diarrhea has cleared up"
+    - "only one or two loose stools"
+    - "diarrhea much better"
+    - "stomach is settling down"
+    - "stools are solid now"
+    - "stool is formed"
+    - "bathroom trips back to normal"
+    - "no more loose stools"
+    - "no more watery stools"
+    - "stopped having diarrhea"
+    # --- incontinence frequency context (R1 post_procedure_incontinence) ---
+    - "incontinence"
+    - "incontinence episodes"
+    - "leaking episodes"
+    - "urine leakage"
+    - "urine leakage episodes"
+    - "leaking urine"
+    - "pad changes"
+    - "wearing pads"
+    - "bladder control"
+    - "pelvic floor"
+    - "bladder surgery"
+    - "prostate surgery"
+    - "prostate procedure"
+    - "catheter"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/severe_hypoglycemia/flows/clarify.yaml b/decision/taxonomy/severe_hypoglycemia/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b33a0a41349df83197bee133d4997ad5c6b869a0
--- /dev/null
+++ b/decision/taxonomy/severe_hypoglycemia/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: severe_hypoglycemia
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: severe_hypoglycemia_clarify
+      goal: "Ask patient to describe their severe hypoglycemia symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - severe_hypoglycemia_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/severe_hypoglycemia/flows/escalate_r3.yaml b/decision/taxonomy/severe_hypoglycemia/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5aea253c856125ece30131509621331d54683a41
--- /dev/null
+++ b/decision/taxonomy/severe_hypoglycemia/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: severe_hypoglycemia
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Inform patient this requires immediate clinical attention and they will be transferred"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/severe_hypoglycemia/flows/handoff.yaml b/decision/taxonomy/severe_hypoglycemia/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..02b5ba57fbb29abb85028225102de0d57edfb5bd
--- /dev/null
+++ b/decision/taxonomy/severe_hypoglycemia/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: severe_hypoglycemia
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: severe_hypoglycemia_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: severe_hypoglycemia_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/severe_hypoglycemia/rules.yaml b/decision/taxonomy/severe_hypoglycemia/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7ae698b90608a087adbdde20a17f53fdcc26a462
--- /dev/null
+++ b/decision/taxonomy/severe_hypoglycemia/rules.yaml
@@ -0,0 +1,21 @@
+domain: severe_hypoglycemia
+target_risk_class: R3
+
+decision_rules:
+  - id: severe_hypoglycemia_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r3
+
+  - id: severe_hypoglycemia_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r3
+
+  - id: severe_hypoglycemia_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/severe_hypoglycemia/triggers.yaml b/decision/taxonomy/severe_hypoglycemia/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7972b4dae4632b391100ddff080eb59a89a05db4
--- /dev/null
+++ b/decision/taxonomy/severe_hypoglycemia/triggers.yaml
@@ -0,0 +1,127 @@
+domain: severe_hypoglycemia
+priority: 87
+
+lexical_signals:
+  high:
+    phrases:
+      - "blood sugar dangerously low"
+      - "severe hypoglycemia"
+      - "sugar dropped and confused"
+      - "blood sugar below 40"
+      - "low blood sugar and can't think straight"
+      - "hypoglycemic and disoriented"
+      - "sugar is crashing"
+      - "blood sugar is dropping"
+    regex:
+      - "(severe|dangerous)\\s+hypoglycemia"
+      - "blood\\s+sugar\\s+(below|under)\\s+\\d{2}\\b"
+      - "sugar.{0,20}(crash|drop|dip|low|plummet|tanking)"
+      - "(shaky|shaking|trembl).{0,30}(sweat|perspir).{0,30}(confus|dizzy|can't think|foggy)"
+      - "(meter|glucometer|reading|glucose|sugar).{0,25}\\b([2-4]\\d|5[0-3])\\s*(mg|mg/dl)"
+      - "\\b([2-4]\\d|5[0-3])\\s*mg.{0,5}dl"
+      - "(type\\s+1|T1D|insulin|pump).{0,40}(shak|sweat|foggy|dizzy|wobbly|off|weak)"
+  medium:
+    phrases:
+      - "blood sugar very low"
+      - "low sugar and shaking"
+      - "hypoglycemic episode"
+      - "sugar crashed"
+      - "feeling very shaky and sweating"
+      - "blood sugar dropped significantly"
+      - "my sugar is doing that bad dip thing"
+      - "shaky and sweaty"
+      - "sweaty and shaky"
+      - "can't think straight and shaky"
+      - "hands are shaking and sweating"
+      - "sugar is low"
+      - "my sugar dropped"
+      - "meter says"
+      - "insulin pump and shaky"
+      - "diabetes and shaky"
+      - "diabetes and sweating"
+    regex:
+      - "(shak|trembl).{0,20}(sweat|perspir)"
+      - "(sweat).{0,20}(shak|trembl)"
+      - "sugar.{0,15}(low|drop|dip|bad)"
+      - "my sugar.{0,20}(doing|acting|going)"
+      - "(dizzy|lightheaded|foggy|confused).{0,20}(shak|sweat)"
+  low:
+    partials:
+      - "hypoglycemia"
+      - "low sugar"
+      - "low blood sugar"
+      - "sugar low"
+      - "blood sugar"
+      - "shaky and sweaty"
+
+negation_handling:
+  patterns:
+    - "blood sugar is normal"
+    - "blood sugar is controlled"
+    - "blood sugar is stable"
+    - "blood sugar is fine"
+    - "sugar is controlled"
+    - "sugar is fine"
+    - "sugar is stable"
+    - "no hypoglycemia"
+    - "diabetes well controlled"
+    - "diabetes is controlled"
+    - "my diabetes is controlled"
+    # --- glucose_out_of_range (R1) mild/routine context ---
+    - "blood sugar a little high"
+    - "blood sugar a bit high"
+    - "sugar a little high"
+    - "sugar a bit high"
+    - "blood sugar running high"
+    - "sugar running high"
+    - "blood sugar out of range"
+    - "glucose out of range"
+    - "blood sugar numbers are off"
+    - "sugar numbers are off"
+    - "not dangerously low"
+    - "not that low"
+    - "sugar is just a bit off"
+    - "sugar readings have been"
+    - "checking blood sugar"
+    - "blood sugar has been"
+    - "monitoring my sugar"
+    - "tracking my blood sugar"
+    - "sugar has been a little"
+    - "blood sugar slightly"
+    - "no shaking"
+    - "no sweating"
+    - "not shaky"
+    - "not sweating"
+    - "feeling fine otherwise"
+    - "I feel fine"
+    - "just the numbers"
+    # --- routine diabetes management context ---
+    - "A1C"
+    - "hemoglobin A1C"
+    - "metformin"
+    - "managing my diabetes"
+    - "diabetes management"
+    - "my doctor told me to check"
+    - "routine glucose check"
+    - "glucose readings"
+    - "blood sugar readings"
+    - "been checking my blood sugar"
+    - "been monitoring"
+    - "in the 140s"
+    - "in the 150s"
+    - "in the 160s"
+    - "in the 170s"
+    - "in the 180s"
+    - "readings have been"
+    - "adjusting my medication"
+    - "dosing question"
+    - "energy levels are normal"
+    - "energy levels are fine"
+    - "feel fine physically"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/shortness_of_breath_rest/flows/clarify.yaml b/decision/taxonomy/shortness_of_breath_rest/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f9457b3a22f3613bd284a286f6aeed4d72d7688a
--- /dev/null
+++ b/decision/taxonomy/shortness_of_breath_rest/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: shortness_of_breath_rest
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: shortness_of_breath_rest_clarify
+      goal: "Ask patient to describe their shortness of breath rest symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - shortness_of_breath_rest_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/shortness_of_breath_rest/flows/escalate_r3.yaml b/decision/taxonomy/shortness_of_breath_rest/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..96e16999c4b02516acb5ecb14921f5a3c17668d7
--- /dev/null
+++ b/decision/taxonomy/shortness_of_breath_rest/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: shortness_of_breath_rest
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Inform patient this requires immediate clinical attention and they will be transferred"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/shortness_of_breath_rest/flows/handoff.yaml b/decision/taxonomy/shortness_of_breath_rest/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d298d530cd73e797d02c908dbbc698692edce81d
--- /dev/null
+++ b/decision/taxonomy/shortness_of_breath_rest/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: shortness_of_breath_rest
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: shortness_of_breath_rest_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: shortness_of_breath_rest_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/shortness_of_breath_rest/flows/reassure_low_risk.yaml b/decision/taxonomy/shortness_of_breath_rest/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9668527e34ba94ff2edf9649836c954601eec721
--- /dev/null
+++ b/decision/taxonomy/shortness_of_breath_rest/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: shortness_of_breath_rest
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: sob_rest_reassure
+      goal: "Acknowledge the patient's concern about breathing, note that their care team will be informed for routine follow-up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/shortness_of_breath_rest/flows/safety_screen.yaml b/decision/taxonomy/shortness_of_breath_rest/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..87c91bdc08d1b3a3a88396412793b0f99a9432bf
--- /dev/null
+++ b/decision/taxonomy/shortness_of_breath_rest/flows/safety_screen.yaml
@@ -0,0 +1,54 @@
+flow_id: safety_screen
+type: screening
+domain: shortness_of_breath_rest
+
+required_slots:
+  - sob_at_rest
+  - sob_onset
+  - exertion_context
+  - breathing_effort
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: sob_rest_screen_step1
+      goal: "Determine whether shortness of breath occurs at rest or only with exertion"
+      tone: calm_urgent
+      must_include:
+        - "breathing"
+      must_ask:
+        - "Are you short of breath right now while sitting or lying still?"
+        - "When did the breathing difficulty start?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - sob_at_rest
+      - sob_onset
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: sob_rest_screen_step2
+      goal: "Screen for exertion-only versus rest-state breathing difficulty"
+      tone: calm_urgent
+      must_include:
+        - "understand"
+      must_ask:
+        - "Does the shortness of breath only happen when you're active or moving around?"
+        - "How hard is it to take a full breath right now?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - exertion_context
+      - breathing_effort
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_r3
diff --git a/decision/taxonomy/shortness_of_breath_rest/rules.yaml b/decision/taxonomy/shortness_of_breath_rest/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..91a2540bf120afbbd306d7c6af4e3ce27c919c4e
--- /dev/null
+++ b/decision/taxonomy/shortness_of_breath_rest/rules.yaml
@@ -0,0 +1,27 @@
+domain: shortness_of_breath_rest
+target_risk_class: R3
+
+decision_rules:
+  - id: shortness_of_breath_rest_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: shortness_of_breath_rest_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: shortness_of_breath_rest_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: shortness_of_breath_rest_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
diff --git a/decision/taxonomy/shortness_of_breath_rest/triggers.yaml b/decision/taxonomy/shortness_of_breath_rest/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a3a67c94d87914adb4c8e4abc2b600412385c8b5
--- /dev/null
+++ b/decision/taxonomy/shortness_of_breath_rest/triggers.yaml
@@ -0,0 +1,157 @@
+domain: shortness_of_breath_rest
+priority: 99
+
+lexical_signals:
+  high:
+    phrases:
+      - "can't breathe"
+      - "shortness of breath at rest"
+      - "breathing getting worse rapidly"
+      - "struggling to breathe"
+      - "can't catch my breath"
+      - "gasping for air"
+      - "suffocating"
+      - "oxygen level dropping"
+      - "severe shortness of breath"
+      - "short of breath just sitting"
+      - "short of breath at rest"
+      - "can't get a full breath"
+      - "winded just sitting here"
+      - "breathing is really hard"
+    regex:
+      - "can'?t\\s+(breathe|catch\\s+my\\s+breath|get\\s+(a\\s+)?full\\s+breath)"
+      - "short\\s+of\\s+breath"
+      - "(winded|breathless).{0,20}(sit|rest|still|nothing|just)"
+      - "(can'?t|hard\\s+to|difficult\\s+to|struggle\\s+to|unable\\s+to)\\s+(breathe|get\\s+air|get\\s+breath)"
+  medium:
+    phrases:
+      - "having trouble breathing"
+      - "breathing is hard"
+      - "winded sitting still"
+      - "labored breathing"
+      - "respiratory distress"
+      - "short of breath doing nothing"
+      - "breathing difficulty at rest"
+      - "hard to pull air in"
+      - "feel like I can't get enough air"
+      - "my breathing is off"
+      - "I'm kind of winded"
+      - "I'm a little winded"
+      - "harder to breathe"
+      # --- additional naturalistic ---
+      - "can't get comfortable breathing"
+      - "have to sit up to breathe"
+      - "woke up gasping"
+    regex:
+      - "(trouble|difficulty|problem).{0,15}breath"
+      - "breath.{0,15}(hard|difficult|labored|shallow|rapid)"
+      - "(winded|breathless|panting)"
+      - "hard.{0,10}(to\\s+)?breath"
+      - "pull\\s+air\\s+in"
+      - "get\\s+(enough\\s+)?air"
+  low:
+    partials:
+      - "breathless"
+      - "dyspnea"
+      - "out of breath"
+      - "short of breath"
+
+negation_handling:
+  patterns:
+    - "no breathing problems"
+    - "breathing is fine now"
+    - "shortness of breath resolved"
+    - "when i exercise"
+    - "when exercising"
+    - "when i walk"
+    - "when walking"
+    - "when i climb"
+    - "when climbing"
+    - "with exertion"
+    - "during exercise"
+    - "during exertion"
+    - "while exercising"
+    - "with activity"
+    - "during activity"
+    - "when i'm active"
+    - "on exertion"
+    - "with physical"
+    - "after exercise"
+    - "after walking"
+    - "after climbing"
+    - "after exertion"
+    - "when i run"
+    - "when running"
+    - "with effort"
+    - "going up stairs"
+    - "going upstairs"
+    - "up stairs"
+    - "up the stairs"
+    - "climbing stairs"
+    - "flight of stairs"
+    - "flights of stairs"
+    - "push myself"
+    - "if i push"
+    - "hills"
+    - "uphill"
+    - "when i move"
+    - "when moving"
+    - "only when"
+    - "just when"
+    - "doing chores"
+    - "doing housework"
+    - "mowing"
+    - "vacuuming"
+    - "gardening"
+    - "working out"
+    - "on the treadmill"
+    - "on my walk"
+    - "during my walk"
+    - "after jogging"
+    - "when jogging"
+    - "during jogging"
+    - "after running"
+    - "while running"
+    - "after a jog"
+    - "after a run"
+    - "when i jog"
+    - "with walking"
+    - "with climbing"
+    - "with exercise"
+    - "with stairs"
+    - "after a hike"
+    - "when hiking"
+    - "during physical activity"
+    - "only with activity"
+    - "only during exercise"
+    - "only when walking"
+    - "only when i exert"
+    - "after physical exertion"
+    # --- R1 screening denial coverage ---
+    - "no shortness of breath"
+    - "not short of breath"
+    - "no breathing problems"
+    - "no trouble breathing"
+    - "breathing fine"
+    - "breathing is fine"
+    - "breathing is okay"
+    - "no difficulty breathing"
+    - "can breathe fine"
+    - "breathing normally"
+    - "not winded at rest"
+    - "not breathless"
+    - "I can breathe okay"
+    - "no breathing issues"
+    - "lungs feel fine"
+    # --- historical / administrative context (FDA-safe) ---
+    - "years ago"
+    - "in the past"
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+    - "appointment timing"
+  # Changed to 'suppress' for R1 false escalation reduction.
+  # Activity-based patterns and administrative context should suppress the domain.
+  action: downgrade_confidence
diff --git a/decision/taxonomy/social_isolation/flows/clarify.yaml b/decision/taxonomy/social_isolation/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c3850d2bed9bf355464d9b09813be61297352c12
--- /dev/null
+++ b/decision/taxonomy/social_isolation/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: social_isolation
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: social_isolation_clarify
+      goal: "Ask patient to describe their home situation and any challenges they face with getting help"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "burden"
+      max_questions: 1
+    collects:
+      - social_isolation_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: resource_referral
diff --git a/decision/taxonomy/social_isolation/flows/concern_assessment.yaml b/decision/taxonomy/social_isolation/flows/concern_assessment.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3f86c94700debdfba9e32e889f449fef6a6fdce1
--- /dev/null
+++ b/decision/taxonomy/social_isolation/flows/concern_assessment.yaml
@@ -0,0 +1,52 @@
+flow_id: concern_assessment
+type: assessment
+domain: social_isolation
+
+required_slots:
+  - living_situation
+  - support_network
+  - transportation_access
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: social_isolation_assess_step1
+      goal: "Understand the patient's living situation and whether they have people who help or check on them"
+      tone: warm_empathetic
+      must_include:
+        - "understand"
+      must_ask:
+        - "Can you tell me about your living situation? Do you live alone or with someone?"
+        - "Do you have family or friends who check in on you regularly?"
+      must_not:
+        - "burden"
+        - "sad"
+        - "depressed"
+      max_questions: 2
+    collects:
+      - living_situation
+      - support_network
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: social_isolation_assess_step2
+      goal: "Assess transportation and ability to access medical care and daily necessities"
+      tone: warm_empathetic
+      must_include:
+        - "appointments"
+      must_ask:
+        - "Are you able to get to your medical appointments and the pharmacy when you need to?"
+      must_not:
+        - "burden"
+        - "helpless"
+      max_questions: 1
+    collects:
+      - transportation_access
+
+exit:
+  on_complete: evaluate_concern
+  on_concern: resource_referral
+  on_low_risk: resource_referral
+  on_unclear: resource_referral
diff --git a/decision/taxonomy/social_isolation/flows/resource_referral.yaml b/decision/taxonomy/social_isolation/flows/resource_referral.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ca39c5287ec3a8c4e7fc380afc32b983139793e3
--- /dev/null
+++ b/decision/taxonomy/social_isolation/flows/resource_referral.yaml
@@ -0,0 +1,23 @@
+flow_id: resource_referral
+type: resolution
+domain: social_isolation
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: social_isolation_resource_referral
+      goal: "Inform the patient that their care team will connect them with community resources for transportation, social support, and daily assistance"
+      tone: warm_empathetic
+      must_include:
+        - "care team"
+        - "resources"
+        - "support"
+      must_not:
+        - "burden"
+        - "helpless"
+        - "charity"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/social_isolation/rules.yaml b/decision/taxonomy/social_isolation/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..964263c8ee02f4b10ffb50fd65eee4b927e3c720
--- /dev/null
+++ b/decision/taxonomy/social_isolation/rules.yaml
@@ -0,0 +1,27 @@
+domain: social_isolation
+target_risk_class: R1
+
+decision_rules:
+  - id: social_isolation_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: concern_assessment
+
+  - id: social_isolation_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: concern_assessment
+
+  - id: social_isolation_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: social_isolation_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: resource_referral
diff --git a/decision/taxonomy/social_isolation/triggers.yaml b/decision/taxonomy/social_isolation/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6e20b11ce8d6e650f4e205e9bdee89547d30c408
--- /dev/null
+++ b/decision/taxonomy/social_isolation/triggers.yaml
@@ -0,0 +1,73 @@
+domain: social_isolation
+priority: 30
+
+lexical_signals:
+  high:
+    phrases:
+      - "living alone and can't get help"
+      - "no one to talk to"
+      - "completely isolated"
+      - "can't get to my appointments"
+      - "no family nearby and I'm struggling"
+      - "no one checks on me"
+      - "all alone and can't manage"
+      - "have nobody to help me"
+      - "no transportation to the doctor"
+      - "can't get my groceries"
+      - "haven't talked to anyone in weeks"
+      - "no support at all"
+      - "alone and can't take care of myself"
+      - "no one to drive me"
+      - "stuck at home with no help"
+    regex:
+      - "(no\\s+one|nobody|don't\\s+have\\s+anyone).{0,20}(help|talk|check|visit|drive|take\\s+me)"
+      - "(can't|cannot|unable\\s+to)\\s+get\\s+to.{0,15}(appointment|doctor|pharmacy|store|hospital)"
+      - "(completely|totally|very|extremely).{0,10}(isolated|alone|lonely)"
+      - "(no|don't\\s+have).{0,10}(family|friends|support|help).{0,10}(nearby|close|around|available)"
+  medium:
+    phrases:
+      - "living alone"
+      - "lonely"
+      - "isolated"
+      - "no family nearby"
+      - "hard to get to appointments"
+      - "don't have transportation"
+      - "no one around"
+      - "by myself most of the time"
+      - "don't see people much"
+      - "no visitors"
+      - "can't get out much"
+      - "stuck at home"
+      - "no rides"
+    regex:
+      - "(living|live)\\s+(alone|by\\s+myself)"
+      - "(no|don't\\s+have|lack).{0,10}(transportation|rides|way\\s+to\\s+get)"
+      - "(lonely|lonesome|isolated).{0,10}(lately|recently|always|often)"
+  low:
+    partials:
+      - "alone"
+      - "lonely"
+      - "isolated"
+      - "no rides"
+      - "transportation"
+
+negation_handling:
+  patterns:
+    - "not lonely"
+    - "have plenty of support"
+    - "family visits often"
+    - "not isolated"
+    - "have people around"
+    - "good support system"
+    - "have family nearby"
+    - "my family is nearby"
+    - "friends check on me"
+    - "i have transportation"
+    - "got transportation"
+    - "can get to appointments"
+    - "son drives me"
+    - "daughter helps me"
+    - "neighbor takes me"
+    - "have a ride"
+    - "not alone"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/stroke_symptoms/flows/clarify.yaml b/decision/taxonomy/stroke_symptoms/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e2fe593da1ed3de34dc74d81161d9086da793c2c
--- /dev/null
+++ b/decision/taxonomy/stroke_symptoms/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: stroke_symptoms
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: stroke_symptoms_clarify
+      goal: "Ask patient to describe their stroke symptoms symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - stroke_symptoms_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/stroke_symptoms/flows/escalate_r3.yaml b/decision/taxonomy/stroke_symptoms/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1b2b0fc9bb2037a3590ab8348e07b15fc5505ac9
--- /dev/null
+++ b/decision/taxonomy/stroke_symptoms/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: stroke_symptoms
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Inform patient this requires immediate clinical attention and they will be transferred"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/stroke_symptoms/flows/handoff.yaml b/decision/taxonomy/stroke_symptoms/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..beb67c75886ba645ae72e6d7e753fcca64ff897f
--- /dev/null
+++ b/decision/taxonomy/stroke_symptoms/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: stroke_symptoms
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: stroke_symptoms_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: stroke_symptoms_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/stroke_symptoms/flows/reassure_low_risk.yaml b/decision/taxonomy/stroke_symptoms/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..215ad38fba0db0ae0fef1c4f28fe80bb63c15320
--- /dev/null
+++ b/decision/taxonomy/stroke_symptoms/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: stroke_symptoms
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: stroke_symptoms_reassure
+      goal: "Acknowledge the patient's concern about neurological symptoms, note that their care team will be informed for routine follow-up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/stroke_symptoms/flows/safety_screen.yaml b/decision/taxonomy/stroke_symptoms/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..43755e9dc779ecd2a4259bfc25483244aa63b83d
--- /dev/null
+++ b/decision/taxonomy/stroke_symptoms/flows/safety_screen.yaml
@@ -0,0 +1,75 @@
+flow_id: safety_screen
+type: screening
+domain: stroke_symptoms
+
+required_slots:
+  - balance_deficit
+  - vision_change
+  - facial_droop
+  - arm_weakness
+  - speech_slurring
+  - symptom_onset_time
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: stroke_screen_befast
+      goal: "Screen for BE-FAST balance and eye symptoms"
+      tone: calm_urgent
+      must_include:
+        - "important"
+      must_ask:
+        - "Are you having any trouble with balance or coordination?"
+        - "Have you noticed any sudden changes in your vision?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - balance_deficit
+      - vision_change
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: stroke_screen_step1
+      goal: "Screen for classic FAST stroke indicators"
+      tone: calm_urgent
+      must_include:
+        - "important"
+      must_ask:
+        - "Is one side of your face drooping or feeling numb?"
+        - "Can you raise both arms — is one arm weak or drifting down?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - facial_droop
+      - arm_weakness
+
+  - step: 3
+    type: ask
+    response_spec:
+      id: stroke_screen_step2
+      goal: "Screen for speech changes and determine timing"
+      tone: calm_urgent
+      must_include:
+        - "need to know"
+      must_ask:
+        - "Is your speech slurred or are you having trouble getting words out?"
+        - "When did these symptoms start?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - speech_slurring
+      - symptom_onset_time
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_r3
diff --git a/decision/taxonomy/stroke_symptoms/rules.yaml b/decision/taxonomy/stroke_symptoms/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4da9ce04d90d47418432b8f6184f51cf808dd3ae
--- /dev/null
+++ b/decision/taxonomy/stroke_symptoms/rules.yaml
@@ -0,0 +1,27 @@
+domain: stroke_symptoms
+target_risk_class: R3
+
+decision_rules:
+  - id: stroke_symptoms_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: stroke_symptoms_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: stroke_symptoms_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: stroke_symptoms_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
diff --git a/decision/taxonomy/stroke_symptoms/triggers.yaml b/decision/taxonomy/stroke_symptoms/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8ac43f58476950e085d46d71cd7e59d3492e6b5d
--- /dev/null
+++ b/decision/taxonomy/stroke_symptoms/triggers.yaml
@@ -0,0 +1,154 @@
+domain: stroke_symptoms
+priority: 98
+
+lexical_signals:
+  high:
+    phrases:
+      - "face is drooping"
+      - "can't move my arm"
+      - "slurred speech"
+      - "stroke"
+      - "one side of my body is weak"
+      - "sudden numbness on one side"
+      - "can't speak clearly"
+      - "facial droop"
+      - "one side of my face"
+      - "arm isn't working"
+      - "can't lift my arm"
+    regex:
+      - "(face|facial).{0,12}(droop|numb|sag|weak|lopsid)"
+      - "slurred\\s+speech"
+      - "(can'?t|unable\\s+to|couldn'?t)\\s+(move|lift|feel|use)\\s+(my\\s+)?(arm|hand|leg|side)"
+      - "(arm|hand|leg|side).{0,15}(isn'?t|not|won'?t|can'?t).{0,10}(work|cooperat|mov|respond)"
+      - "(one|left|right)\\s+side.{0,15}(weak|numb|heavy|dead|not working|tingl)"
+      - "sudden.{0,10}(numb|weak|tingl).{0,15}(one side|left|right|arm|leg|face)"
+  medium:
+    phrases:
+      - "face feels numb"
+      - "arm is tingling on one side"
+      - "words coming out wrong"
+      - "sudden confusion"
+      - "trouble speaking suddenly"
+      - "vision loss in one eye"
+      - "sudden weakness one side"
+      - "hand isn't cooperating"
+      - "words aren't coming out right"
+      - "speech sounds funny"
+      - "trouble with words"
+      - "hand feels like it's not mine"
+      - "arm feels heavy and won't work"
+      - "words are coming out wrong"
+      - "words are coming out weird"
+      - "words coming out garbled"
+      - "words coming out thick"
+      - "face feels droopy"
+      - "tongue feels thick"
+      - "tongue is heavy"
+      - "tongue was clumsy"
+      - "hand felt like it wasn't mine"
+      - "arm felt like it wasn't mine"
+      - "not making sense"
+      - "not making much sense"
+      - "talking kind of funny"
+      - "words were thick"
+      - "words feel mushy"
+      - "words didn't match"
+      - "words didn't match what I was thinking"
+      - "talking feels sticky"
+      - "keep losing the word I want"
+      - "hand keeps letting go of things"
+      - "keep dropping things"
+      - "left side feels tingly"
+      # --- MINIMIZER coverage ---
+      - "feeling a bit off"
+      - "body's lagging"
+      - "bumped into the doorway"
+      - "lip feels sort of tingly"
+      - "words feel stuck"
+      - "face looks different"
+      - "body isn't cooperating"
+      - "legs feel kind of funny"
+    regex:
+      - "(word|speech|speak|talk).{0,30}(wrong|funny|garbled|slur|trouble|off|weird|jumbled|thick|mushy|sticky|match)"
+      - "(hand|arm|leg|foot).{0,25}(not mine|foreign|dead|heavy|weird|numb|tingle|clumsy|wasn.t mine)"
+      - "(trouble|difficulty|problem).{0,10}(speak|talk|word|typing|writing)"
+      - "(hand|arm).{0,15}(letting\\s+go|keeps?\\s+dropping|won't\\s+hold|can't\\s+grip)"
+      - "(losing|lost|can't\\s+find).{0,15}(the\\s+)?word"
+      - "talk.{0,10}feels?.{0,10}(sticky|thick|weird|wrong|off)"
+      - "words?.{0,10}(didn't|don't|did\\s+not).{0,10}(match|come\\s+out)"
+      - "(sudden|all of a sudden|out of nowhere).{0,20}(confus|dizzy|weak|numb)"
+      - "words?.{0,10}coming out.{0,10}(wrong|weird|garbled|thick|funny|mushy|slurred|jumbled)"
+      - "(tongue|mouth).{0,10}(thick|heavy|clumsy|numb|swollen|fat|not working)"
+      - "(not|isn.t|can.t).{0,8}making.{0,6}(much\\s+)?sense"
+      - "words?.{0,10}(feel|felt|sound).{0,10}(mushy|thick|heavy|slurred|garbled|wrong|off)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(body|side).{0,15}(lagging|not cooperating|not responding|feels? off|'s off|is off|seems? off|weird|sluggish)"
+      - "(stumbl|trip|bump).{0,20}(couple|few|times|morning|today|things|doorway|wall|counter)"
+      - "(clumsy|fumbl|clunky|uncoordinated).{0,15}(today|hand|arm|suddenly|this morning|all of a sudden)"
+      - "(tingly|tingling|numb|weird).{0,15}(lip|cheek|face|mouth|chin|jaw)"
+      - "(trouble|having trouble)\\s+organizing.{0,10}(thought|word|sentence)"
+      - "(arm|hand|leg).{0,15}(heavier|not right|shaky|sinking|weaker|not quite right)"
+      - "marbles\\s+in\\s+(my|his|her)\\s+mouth"
+      - "(vision|things|everything).{0,15}(blurry|smeared|off|funny|weird).{0,15}(on|one|left|right|the)\\s+(side|eye)"
+      - "(arm|hand|leg).{0,15}(a bit|kind of|sort of|little).{0,15}(weak|numb|heavy|tingly|off|shaky)"
+  low:
+    partials:
+      - "hemiparesis"
+      - "aphasia"
+      - "dysarthria"
+      - "TIA"
+      - "one side is weak"
+      - "drooping face"
+      - "slurred"
+
+negation_handling:
+  patterns:
+    - "no stroke symptoms"
+    - "face is fine"
+    - "speech is normal"
+    - "no numbness"
+    # --- R1 denial coverage ---
+    - "no facial droop"
+    - "no drooping"
+    - "face looks normal"
+    - "face is symmetrical"
+    - "no slurring"
+    - "not slurring"
+    - "no trouble speaking"
+    - "no arm weakness"
+    - "no weakness on one side"
+    - "arms and legs are fine"
+    - "no confusion"
+    - "not confused"
+    - "not dizzy"
+    - "no dizziness"
+    - "no vision problems"
+    # --- progressive_weakness (R1) chronic/gradual context ---
+    - "gradually getting weaker"
+    - "been getting weaker"
+    - "been weak since"
+    - "weakness for weeks"
+    - "weakness for months"
+    - "chronic weakness"
+    - "chronic fatigue"
+    - "fatigue and weakness"
+    - "since my surgery"
+    - "since I got home"
+    - "since discharge"
+    - "since the procedure"
+    - "physical therapy"
+    - "PT appointment"
+    - "rehab"
+    - "recovering from surgery"
+    - "recovery has been"
+    - "energy levels"
+    - "deconditioning"
+    - "not as strong as before"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/sudden_vision_loss/flows/clarify.yaml b/decision/taxonomy/sudden_vision_loss/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9fb2a948cb486323ac12dd30563e7fc7ea94b343
--- /dev/null
+++ b/decision/taxonomy/sudden_vision_loss/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: sudden_vision_loss
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: sudden_vision_loss_clarify
+      goal: "Ask patient to describe their sudden vision loss symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - sudden_vision_loss_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/sudden_vision_loss/flows/escalate_r3.yaml b/decision/taxonomy/sudden_vision_loss/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1d9a36242f67d90c87645cb3181ebab943868bac
--- /dev/null
+++ b/decision/taxonomy/sudden_vision_loss/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: sudden_vision_loss
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Inform patient this requires immediate clinical attention and they will be transferred"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/sudden_vision_loss/flows/handoff.yaml b/decision/taxonomy/sudden_vision_loss/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3e2d1bc558e455ec5fa51a3e2bb1c3bd90308510
--- /dev/null
+++ b/decision/taxonomy/sudden_vision_loss/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: sudden_vision_loss
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: sudden_vision_loss_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: sudden_vision_loss_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/sudden_vision_loss/rules.yaml b/decision/taxonomy/sudden_vision_loss/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e491daa5e1ca61e6dc6a9739f18f2793c24d7991
--- /dev/null
+++ b/decision/taxonomy/sudden_vision_loss/rules.yaml
@@ -0,0 +1,21 @@
+domain: sudden_vision_loss
+target_risk_class: R3
+
+decision_rules:
+  - id: sudden_vision_loss_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r3
+
+  - id: sudden_vision_loss_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r3
+
+  - id: sudden_vision_loss_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/sudden_vision_loss/triggers.yaml b/decision/taxonomy/sudden_vision_loss/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..337c2badaf87889d141bed35b6129c156c5bd29c
--- /dev/null
+++ b/decision/taxonomy/sudden_vision_loss/triggers.yaml
@@ -0,0 +1,172 @@
+domain: sudden_vision_loss
+priority: 84
+
+lexical_signals:
+  high:
+    phrases:
+      - "suddenly can't see"
+      - "lost vision in one eye"
+      - "went blind suddenly"
+      - "vision gone"
+      - "sudden vision loss"
+      - "can't see anything suddenly"
+      - "eye just went dark"
+      - "can't see out of my eye"
+      - "vision went black"
+      - "eye went blind"
+    regex:
+      - "sudden(ly)?\\s+(can'?t\\s+see|couldn'?t\\s+see|vision\\s+loss|blind|blurr)"
+      - "eye.{0,20}(went|turned|got).{0,15}(dark|black|blind|blank|dim)"
+      - "(can'?t|couldn'?t)\\s+see.{0,20}(out of|with|from).{0,10}eye"
+      - "vision.{0,15}(went|dropped|disappeared|gone|lost|dark)"
+      - "(left|right)\\s+eye.{0,20}(dark|blind|can'?t see|blurr|dim)"
+      # --- reversed word order + caregiver ---
+      - "lost\\s+vision\\s+(in|from|completely)"
+      - "(couldn'?t|can'?t)\\s+see\\s+(anything|out of|part|much)\\s+(out of\\s+)?(that|his|her|my|the)\\s+(eye|right|left)"
+      - "(he|she|my|father|mother|dad|mom).{0,30}lost\\s+vision"
+      - "(went|gone)\\s+(completely\\s+)?(black|dark|blind)\\s+(in\\s+)?(my|his|her|that|one|the)\\s+(eye|right|left)"
+  medium:
+    phrases:
+      - "vision suddenly blurry"
+      - "seeing dark spots suddenly"
+      - "part of vision missing"
+      - "curtain over my eye"
+      - "sudden blurring of vision"
+      - "lost peripheral vision"
+      - "like a curtain dropped"
+      - "eye acting weird"
+      - "vision got smeary"
+      - "everything looks dim"
+      - "shadow in my vision"
+      - "blind spot appeared"
+      - "gray haze"
+      - "washed out vision"
+      - "lower half looked washed out"
+      - "eye went dim"
+      # --- MINIMIZER coverage ---
+      - "vision's been a little funny"
+      - "things looked a bit off"
+      - "everything's kind of fuzzy"
+      - "can't see the words properly"
+      - "dark area in my vision"
+      - "letters went gray"
+      - "vision seems a bit off"
+      - "eye isn't working right"
+      - "can barely see out of it"
+      - "part of my view is gone"
+      - "like someone turned off the lights on that side"
+      - "not seeing right"
+      # --- additional patterns ---
+      - "everything looks washed out"
+      - "colors aren't right"
+      - "things look faded"
+      - "vision went dark then cleared"
+      - "tons of floaters suddenly"
+      - "lots of flashes"
+      - "covering one eye makes it"
+      # --- complete loss phrases ---
+      - "can't see out of one eye"
+      - "can't see out of my left eye"
+      - "can't see out of my right eye"
+      - "vision just went black"
+      - "eye went completely dark"
+      - "lost sight in one eye"
+      - "one eye just stopped working"
+      # --- partial loss phrases ---
+      - "half my vision is gone"
+      - "half my vision disappeared"
+      - "blind spot just appeared"
+      - "dark spot in my vision"
+      - "part of my vision is missing"
+      - "missing a chunk of my vision"
+      - "hole in my vision"
+      - "side of my vision is dark"
+      # --- transient patterns ---
+      - "vision came back but I'm worried"
+      - "sight went dark then cleared"
+      - "went blind for a minute then it came back"
+      - "vision went out but returned"
+      - "temporary blindness in one eye"
+      # --- floaters and flashes ---
+      - "floaters and then vision loss"
+      - "flashes and now can't see"
+      - "seeing flashes and losing vision"
+      - "floaters everywhere and vision going"
+      - "shower of floaters"
+      - "suddenly lots of floaters"
+    regex:
+      - "curtain.{0,15}(eye|vision|dropped|fell)"
+      - "eye.{0,20}(weird|strange|off|funny|acting)"
+      - "vision.{0,15}(blurr|dim|smeary|foggy|cloudy|hazy)"
+      - "(floater|flash).{0,20}(eye|vision)"
+      - "(eye|vision).{0,20}(floater|flash)"
+      - "(gray|grey)\\s+(haze|curtain|film|veil)"
+      - "(half|part).{0,15}(washed|faded|dimmed|dark)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "vision.{0,20}(funny|off|weird|strange|different|not right|not quite)"
+      - "things.{0,15}(look|looked|seem|seemed).{0,15}(off|different|wrong|funny|weird|dim|gray|faded|blurry)"
+      - "(blurry|fuzzy|blurred|hazy|foggy).{0,20}(eye|vision|see|sight|everything)"
+      - "(shadow|dark).{0,15}(area|patch|spot|edge|side|creep|part)"
+      - "(can'?t|couldn'?t|trouble|hard).{0,15}(see|focus|read|make out).{0,15}(right|well|properly|clearly|words|screen)"
+      - "(eye|vision|sight).{0,15}(not right|acting up|playing tricks|went|going|isn'?t right)"
+      - "(screen|letters|words|text).{0,15}(faded|gray|blurry|fuzzy|dim|disappeared)"
+      - "(everything|things).{0,15}(fuzzy|blurry|gray|dim|dark|faded|hazy)"
+      - "can'?t\\s+(quite\\s+)?(see|focus|read|make).{0,15}(properly|right|well|clearly)"
+      # --- from missed scenarios analysis ---
+      - "(couldn'?t|can'?t)\\s+(see|make out).{0,20}(out of|with|from).{0,10}(my|his|her|the|that)"
+      - "(left|right)\\s+side\\s+(just\\s+)?went\\s+(dark|black|blank|dim)"
+      - "(went|gone)\\s+(completely\\s+)?(black|dark)\\s+(sometime|during|in|last)"
+      - "(words|text|letters|newspaper).{0,15}(weren'?t|just weren'?t|not)\\s+(there|visible|clear|readable)"
+      - "(part|half|side)\\s+(of\\s+)?(what I|my vision|my view|my sight).{0,15}(missing|gone|dark|black|blank)"
+      - "(blurriness|blurry|can'?t see).{0,15}(in|from|with)\\s+(my|his|her)\\s+(right|left)\\s+eye"
+      # --- painless vision loss (retinal) ---
+      - "(painless|no pain)\\s+(but\\s+)?(can'?t see|vision|blind|lost sight)"
+      # --- transient (amaurosis fugax) ---
+      - "(vision|sight|seeing)\\s+(came back|cleared|returned)\\s+(but|then|and)"
+      # --- sudden floaters/flashes ---
+      - "(tons?|lots?|sudden|many|bunch)\\s+(of\\s+)?(floaters|flashes)"
+      # --- complete loss patterns ---
+      - "(can'?t|couldn'?t)\\s+see\\s+(out\\s+of\\s+)?(one|my|this|that|left|right)\\s+eye"
+      - "(vision|sight)\\s+(just\\s+)?(went|gone|disappeared|vanished)\\s+(black|dark|completely)"
+      - "(everything|world)\\s+(went|gone|turned)\\s+(black|dark)\\s+(in|from|with)\\s+(one|my|this)\\s+eye"
+      # --- partial loss patterns ---
+      - "(half|part|portion|section)\\s+(of\\s+)?(my\\s+)?vision\\s+(is\\s+)?(gone|missing|dark|black|blank)"
+      - "(blind\\s+spot|dark\\s+spot|black\\s+spot)\\s+(appeared|showed\\s+up|just\\s+appeared|out\\s+of\\s+nowhere)"
+      - "(upper|lower|left|right)\\s+(half|part|side)\\s+(of\\s+)?vision\\s+(is\\s+)?(gone|dark|missing)"
+      - "(chunk|piece|area)\\s+(of\\s+)?(my\\s+)?vision\\s+(is\\s+)?(missing|gone|dark)"
+      # --- transient loss patterns ---
+      - "(vision|sight)\\s+(came\\s+back|returned|cleared)\\s+(but|after|then|and\\s+then)"
+      - "(went\\s+dark|blacked\\s+out|couldn'?t\\s+see).{0,20}(then|but).{0,15}(came\\s+back|cleared|returned)"
+      - "(temporary|briefly|for\\s+a\\s+(moment|minute|second|bit))\\s+(couldn'?t\\s+see|lost\\s+vision|went\\s+dark)"
+      # --- associated symptoms ---
+      - "(floaters|flashes).{0,15}(and|with|then).{0,15}(vision\\s+loss|can'?t\\s+see|dark|blind)"
+      - "(vision\\s+loss|can'?t\\s+see).{0,15}(and|with|plus).{0,15}(floaters|flashes)"
+      - "(flashing\\s+lights|light\\s+flashes).{0,15}(then|and|before).{0,15}(couldn'?t\\s+see|vision)"
+  low:
+    partials:
+      - "vision loss"
+      - "blind spot"
+      - "amaurosis"
+      - "can't see right"
+      - "eye is blurry"
+      - "seeing spots"
+      - "fuzzy vision"
+      - "blurry eye"
+
+negation_handling:
+  patterns:
+    - "vision is fine"
+    - "can see clearly"
+    - "no vision problems"
+    # --- R1 denial coverage ---
+    - "eyes are fine"
+    - "vision is normal"
+    - "no blurriness"
+    - "not blurry"
+    - "no blind spots"
+    - "no dark spots"
+    - "no vision changes"
+    - "vision hasn't changed"
+    - "no trouble seeing"
+    - "no eye problems"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/suicidal_ideation/flows/clarify.yaml b/decision/taxonomy/suicidal_ideation/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..75e3270c08986229d262db405335eb30a1b5706d
--- /dev/null
+++ b/decision/taxonomy/suicidal_ideation/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: suicidal_ideation
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: suicidal_ideation_clarify
+      goal: "Ask patient to describe their suicidal ideation symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - suicidal_ideation_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/suicidal_ideation/flows/escalate_r3.yaml b/decision/taxonomy/suicidal_ideation/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..04bd7a3b4856a7bb14c64a34c03d31dacf501145
--- /dev/null
+++ b/decision/taxonomy/suicidal_ideation/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: suicidal_ideation
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Inform patient this requires immediate clinical attention and they will be transferred"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/suicidal_ideation/flows/handoff.yaml b/decision/taxonomy/suicidal_ideation/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..58092ba76ca2a9a9feb3cf20d97fa8cd9ce820c4
--- /dev/null
+++ b/decision/taxonomy/suicidal_ideation/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: suicidal_ideation
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: suicidal_ideation_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: suicidal_ideation_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/suicidal_ideation/rules.yaml b/decision/taxonomy/suicidal_ideation/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9a2cfe20da5cdf8b099ac076146ab048311fb9a6
--- /dev/null
+++ b/decision/taxonomy/suicidal_ideation/rules.yaml
@@ -0,0 +1,21 @@
+domain: suicidal_ideation
+target_risk_class: R3
+
+decision_rules:
+  - id: suicidal_ideation_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r3
+
+  - id: suicidal_ideation_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r3
+
+  - id: suicidal_ideation_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/suicidal_ideation/triggers.yaml b/decision/taxonomy/suicidal_ideation/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..edf083a50820f283ca2d88d5ce0711b3c737503a
--- /dev/null
+++ b/decision/taxonomy/suicidal_ideation/triggers.yaml
@@ -0,0 +1,191 @@
+domain: suicidal_ideation
+priority: 94
+
+lexical_signals:
+  high:
+    phrases:
+      - "want to kill myself"
+      - "suicidal thoughts"
+      - "thinking about ending my life"
+      - "don't want to be alive"
+      - "planning to hurt myself"
+      - "want to die"
+      - "going to end it"
+      - "shouldn't be here anymore"
+      - "don't want to be here anymore"
+      - "thinking about not being here"
+      - "don't wanna be here"
+      - "tired of being here"
+      - "won't have to worry about me"
+      # --- passive ideation phrases ---
+      - "wish I wouldn't wake up"
+      - "don't want to exist"
+      - "wish I could just not wake up"
+      - "go to sleep and not wake up"
+      - "not wake up tomorrow"
+      - "just not exist anymore"
+      # --- method contemplation phrases ---
+      - "staring at pills"
+      - "looking at the bridge"
+      - "have a plan"
+      - "I have a plan"
+      - "know exactly how"
+      - "lethal dosing"
+      - "researching methods"
+      - "looked up lethal"
+      # --- euphemistic language phrases ---
+      - "end the pain"
+      - "permanent solution"
+      - "make it stop permanently"
+      - "end it all"
+      - "end this suffering"
+      - "final solution"
+      - "only way out"
+      # --- burden statements phrases ---
+      - "everyone better off without me"
+      - "just a burden"
+      - "they'd be better without me"
+      - "life insurance would help them more"
+      - "dragging everyone down"
+      # --- hopelessness cluster phrases ---
+      - "no way out"
+      - "nothing matters anymore"
+      - "no point in going on"
+      - "no reason to go on"
+      - "can't see a future"
+      - "no future for me"
+    regex:
+      - "(want|going|plan)\\s+to\\s+(kill|end|hurt)\\s+(myself|my\\s+life|it\\s+all|it)"
+      - "(don'?t|do not)\\s+(want|deserve)\\s+to\\s+(be\\s+alive|live|be\\s+here|exist)"
+      - "(shouldn'?t|should not)\\s+be\\s+here"
+      - "(thinking|thought).{0,10}(about|of).{0,10}(not being here|ending|killing|dying|suicide)"
+      - "(better|easier).{0,20}(off|if).{0,30}(dead|gone|without me|wasn'?t|not here|didn'?t exist)"
+      - "(don'?t|do not|doesn'?t).{0,5}wanna?.{0,5}be\\s+here"
+      - "tired\\s+of\\s+being\\s+here"
+      - "won'?t\\s+have\\s+to\\s+worry"
+      - "what\\s+if\\s+I\\s+(just\\s+)?(wasn'?t|weren'?t|wasn't)\\s+here"
+      - "if\\s+I\\s+(just\\s+)?(stopped|didn'?t|wasn'?t|weren't)"
+      # --- passive ideation regex ---
+      - "(wish|hope|pray|want)\\s+(I\\s+)?(wouldn'?t|didn'?t|don'?t|could\\s+just\\s+not)\\s+(wake|exist|be\\s+here)"
+      - "(go|went)\\s+to\\s+sleep\\s+and\\s+(not|never)\\s+wake"
+      - "not\\s+wake\\s+up\\s+(tomorrow|again|ever)"
+      - "(just\\s+)?not\\s+exist\\s+(anymore|any\\s+more)"
+      # --- method contemplation regex ---
+      - "(staring|stared|looking)\\s+(at|into)\\s+(the\\s+)?(pill|bridge|gun|rope|knife|razor|edge|bottle|medication|balcony|ledge|tracks)"
+      - "(have|got|made)\\s+a\\s+(plan|method|way)"
+      - "(know|figured out|researched)\\s+(exactly\\s+)?how\\s+(I|to)"
+      - "(lethal|fatal)\\s+(dose|dosing|amount)"
+      - "(looked|looking|research)\\s+(up|into)\\s+(lethal|methods|ways\\s+to)"
+      # --- euphemistic language regex ---
+      - "(end|stop)\\s+(the|this|my)\\s+(pain|suffering|struggle|misery)"
+      - "(permanent|final)\\s+(solution|answer|escape|rest|relief)"
+      - "(only|no\\s+other)\\s+(way\\s+)?out"
+      - "end\\s+it\\s+all"
+      - "make\\s+it\\s+(all\\s+)?stop"
+      # --- burden statements regex ---
+      - "(everyone|they|family|my\\s+wife|my\\s+husband|my\\s+kids).{0,20}(better|easier).{0,20}(off|without)\\s+(me|I)"
+      - "(just|nothing\\s+but|only)\\s+a\\s+burden"
+      - "(dragging|bringing|weighing)\\s+(everyone|them|you|my\\s+family)\\s+down"
+      - "life\\s+insurance\\s+would\\s+(help|be\\s+worth)"
+      # --- hopelessness cluster regex ---
+      - "(no|not\\s+any|can'?t\\s+see\\s+a?)\\s+(way\\s+out|future|hope|point|reason)"
+      - "nothing\\s+(matters|will\\s+change|helps)"
+      - "no\\s+point\\s+(in|of|to)\\s+(going\\s+on|living|continuing|trying)"
+      - "no\\s+reason\\s+to\\s+(go\\s+on|live|keep|continue)"
+      - "can'?t\\s+see\\s+(a\\s+)?(future|way\\s+(forward|out)|light)"
+  medium:
+    phrases:
+      - "feel like giving up"
+      - "life isn't worth living"
+      - "thinking about suicide"
+      - "wish I could just disappear"
+      - "better off without me"
+      - "no reason to go on"
+      - "everything would be easier if I wasn't here"
+      - "can't do this anymore"
+      - "don't see the point"
+      - "I just want it to stop"
+      - "I keep thinking I shouldn't be here"
+      - "I said some dumb stuff about not wanting to be around"
+      - "what if I just didn't have to deal"
+      - "just stopped existing"
+      - "if I didn't wake up"
+      # --- indirect / euphemistic ---
+      - "easier if I just"
+      - "you know what I mean"
+      - "not one of those people but"
+      - "wrote letters"
+      - "tying up loose ends"
+      - "everyone would be better"
+      - "just a burden"
+      - "sleep forever"
+      - "want the pain to stop permanently"
+      - "giving away my things"
+      - "said goodbye to everyone"
+      - "making arrangements"
+      - "put my affairs in order"
+      - "no point in fighting anymore"
+      - "I'm done"
+      - "what's the point"
+    regex:
+      - "(give|giving)\\s+up"
+      - "(no|don'?t\\s+see\\s+a?)\\s+(reason|point|purpose).{0,10}(to|for|in).{0,10}(go on|living|life)"
+      - "(wish|want).{0,15}(disappear|vanish|gone|not exist|not be here|not wake)"
+      - "(can'?t|cannot)\\s+(do|take|handle).{0,10}(this|it|anymore|any more)"
+      - "not\\s+want.{0,15}(to be|being)\\s+(around|here|alive)"
+      - "(should|just).{0,10}(disappear|stop existing|not be here|not wake up)"
+      - "didn'?t\\s+(have to|need to|wake|exist|have to deal)"
+      - "saying.{0,15}(scary|dark|concerning)\\s+(stuff|things).{0,20}(hurt|die|end|kill|alive|living)"
+      - "he.{0,5}(don'?t|doesn'?t|didn'?t).{0,5}(wanna|want to).{0,5}be\\s+here"
+      # --- passive ideation ---
+      - "(wish|hope|pray)\\s+(I\\s+)?(wouldn'?t|didn'?t|don'?t)\\s+(wake|exist|have to)"
+      # --- method contemplation ---
+      - "(stared at|looking at|holding)\\s+(the\\s+)?(pill|bridge|gun|rope|knife|razor|edge)"
+      # --- heaviness/emptiness cluster (MINIMIZER/indirect disclosure) ---
+      - "(heavy|empty|tired|fuzzy|dark).{0,30}(feeling|felt|feels|everything)"
+      # --- medication staring/fixation ---
+      - "(stared?\\s+at|looking\\s+at|keep\\s+looking).{0,10}(medication|pill|bottle|drug)"
+      # --- progressive disclosure phrases ---
+      - "everyone\\s+would\\s+be\\s+better\\s+off\\s+without"
+      - "things\\s+have\\s+been\\s+harder"
+      - "can'?t\\s+see\\s+a\\s+way\\s+forward"
+      # --- proxy disclosure ---
+      - "(asking|this is)\\s+(for|about)\\s+a\\s+friend"
+      # --- farewell behavior ---
+      - "(giving away|gave away|giving out)\\s+(my\\s+)?(things|stuff|belongings|possessions)"
+      - "(wrote|writing|written)\\s+(a\\s+)?(letter|note|goodbye|farewell)"
+      - "(tying|tied|putting)\\s+(up\\s+)?(loose ends|affairs|things in order)"
+  low:
+    partials:
+      - "hopeless"
+      - "suicidal"
+      - "self-harm"
+      - "ending it"
+      - "don't want to be here"
+      - "kill myself"
+      - "not worth living"
+      - "stopped existing"
+      - "wanna disappear"
+      - "not be here"
+      - "passing thought about"
+      - "everyone gets those thoughts"
+      - "not going to do anything but"
+      - "burden"
+      - "what's the point"
+      - "done with everything"
+
+negation_handling:
+  patterns:
+    - "not suicidal"
+    - "no thoughts of self-harm"
+    - "don't want to hurt myself"
+    # --- administrative / routine context suppression ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "when can I come in"
+    - "medication refill"
+    - "need a refill"
+    - "routine check"
+    - "just a question"
+    - "appointment timing"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/syncope/flows/clarify.yaml b/decision/taxonomy/syncope/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..52ab558f35c19471e2e1793db1e1419278890249
--- /dev/null
+++ b/decision/taxonomy/syncope/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: syncope
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: syncope_clarify
+      goal: "Ask patient to describe their syncope symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - syncope_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/syncope/flows/escalate_r3.yaml b/decision/taxonomy/syncope/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..721a63d01bb83eec73b3362052253b73d19ca80d
--- /dev/null
+++ b/decision/taxonomy/syncope/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: syncope
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Inform patient this requires immediate clinical attention and they will be transferred"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/syncope/flows/handoff.yaml b/decision/taxonomy/syncope/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3394b174a60fea7543c688a4eb88b79f3eebf0d9
--- /dev/null
+++ b/decision/taxonomy/syncope/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: syncope
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: syncope_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: syncope_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/syncope/rules.yaml b/decision/taxonomy/syncope/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..500514913226f76dedc94f5246d16d1bc7c3f29c
--- /dev/null
+++ b/decision/taxonomy/syncope/rules.yaml
@@ -0,0 +1,21 @@
+domain: syncope
+target_risk_class: R3
+
+decision_rules:
+  - id: syncope_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r3
+
+  - id: syncope_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r3
+
+  - id: syncope_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/syncope/triggers.yaml b/decision/taxonomy/syncope/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9724b965534c4f4ab57dff753cf78e517bfa4496
--- /dev/null
+++ b/decision/taxonomy/syncope/triggers.yaml
@@ -0,0 +1,148 @@
+domain: syncope
+priority: 95
+
+lexical_signals:
+  high:
+    phrases:
+      - "passed out"
+      - "lost consciousness"
+      - "fainted"
+      - "blacked out"
+      - "collapsed"
+      - "syncope"
+      - "fell unconscious"
+      - "fainting spell"
+      - "I fainted"
+      - "just fainted"
+    regex:
+      - "(passed|blacked|black)\\s+out"
+      - "lost\\s+consciousness"
+      - "(faint|collaps)(ed|ing)"
+      - "eyes\\s+(kinda\\s+|kind\\s+of\\s+|just\\s+)?(rolled|went\\s+back)"
+      - "(slumped|crumpled|went\\s+limp)"
+      - "I\\s+did\\s+(black|pass)\\s+out"
+      - "(woke|came\\s+to).{0,10}(on\\s+the\\s+)?(floor|ground)"
+      # --- witness report patterns ---
+      - "(found|saw)\\s+(him|her|them|my).{0,15}(on\\s+)?(the\\s+)?(floor|ground|lying|collapsed)"
+      - "(he|she|they|my).{0,15}(collapsed|went\\s+down|fell\\s+over|crumpled)"
+      - "(husband|wife|father|mother|son|daughter|dad|mom).{0,15}(passed\\s+out|fainted|collapsed|went\\s+down)"
+      # --- post-event confusion ---
+      - "(doesn'?t|didn'?t|don'?t)\\s+remember\\s+(falling|going\\s+down|what\\s+happened|how)"
+      - "(confused|disoriented|dazed)\\s+(after|when|once).{0,15}(woke|came\\s+to)"
+      - "(came\\s+to|woke\\s+up).{0,15}(confused|didn'?t\\s+know|disoriented)"
+      # --- associated symptoms before syncope ---
+      - "(heart|pulse)\\s+(racing|pounding|fast).{0,20}(then|before).{0,15}(passed|blacked|fainted|collapsed)"
+      - "(dizzy|lightheaded|woozy).{0,15}(then|and\\s+then|before).{0,15}(fell|fainted|passed|collapsed|went\\s+down)"
+      - "(sweaty|sweating|clammy).{0,15}(then|and).{0,15}(passed|blacked|fainted|collapsed)"
+  medium:
+    phrases:
+      - "almost fainted"
+      - "felt like I was going to pass out"
+      - "nearly blacked out"
+      - "presyncope"
+      - "lost my balance and fell"
+      - "went down suddenly"
+      - "quick fainting spell"
+      - "blanked out"
+      - "sort of blanked out"
+      - "was on the floor"
+      - "woke up on the floor"
+      - "scared I'm gonna pass out"
+      - "feeling like I might faint"
+      - "don't remember going down"
+      - "don't remember falling"
+      - "next thing I knew I was on the floor"
+      - "I guess I did black out"
+      - "I guess I did pass out"
+      - "eyes rolled and I slumped"
+      - "said my eyes rolled"
+      - "said I slumped"
+      - "looked kind of gray and sweaty"
+      # --- additional naturalistic ---
+      - "they said I went out"
+      - "lights just went out"
+      - "everything went black"
+      # --- witness report patterns ---
+      - "found him on the floor"
+      - "found her on the floor"
+      - "she collapsed"
+      - "he collapsed"
+      - "went down without warning"
+      - "just dropped"
+      - "saw them fall"
+      - "watched her go down"
+      - "watched him go down"
+      # --- near-syncope patterns ---
+      - "thought I was going to faint"
+      - "almost went down"
+      - "nearly fell over"
+      - "felt myself going"
+      - "started to black out"
+      - "was about to pass out"
+      - "felt like passing out"
+      - "almost lost it"
+      - "grayed out"
+      - "vision started going dark"
+      # --- post-event confusion ---
+      - "didn't know where I was"
+      - "confused when I came to"
+      - "didn't recognize anyone"
+      - "took a while to remember"
+      - "groggy after"
+      - "memory is fuzzy"
+      # --- associated symptoms ---
+      - "heart was racing then I passed out"
+      - "got really dizzy then fell"
+      - "sweating then blacked out"
+      - "nauseous before I fainted"
+      - "vision tunneled then I went down"
+    regex:
+      - "(almost|nearly|about to|gonna|going to)\\s+(faint|pass out|black out|collapse)"
+      - "(woke|came to|found myself).{0,10}(on the floor|on the ground)"
+      - "then\\s+I\\s+was\\s+on\\s+the\\s+(floor|ground)"
+      - "(blanked|zoned)\\s+out"
+      - "feeling.{0,10}(faint|woozy|dizzy).{0,20}(fall|drop|pass out)"
+      - "next\\s+thing\\s+I\\s+knew.{0,15}(floor|ground|sitting|lying)"
+      - "(slumped|crumpled).{0,10}(over|down|forward|in)"
+  low:
+    partials:
+      - "vasovagal"
+      - "near-syncope"
+      - "syncope"
+
+negation_handling:
+  patterns:
+    - "didn't faint"
+    - "didn't pass out"
+    - "no loss of consciousness"
+    - "stayed conscious"
+    - "never lost consciousness"
+    - "didn't lose consciousness"
+    - "no syncope"
+    - "haven't fainted"
+    - "haven't passed out"
+    - "have not fainted"
+    - "have not passed out"
+    - "no fainting"
+    - "not fainted"
+    - "not passed out"
+    - "never fainted"
+    - "never passed out"
+    - "haven't blacked out"
+    - "didn't black out"
+    - "haven't collapsed"
+    - "didn't collapse"
+    - "no blackout"
+    - "no passing out"
+    # --- historical / administrative context (FDA-safe) ---
+    - "years ago"
+    - "in the past"
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+    - "appointment timing"
+  # Changed to 'suppress' for R1 false escalation reduction.
+  # Administrative context should suppress the domain.
+  action: downgrade_confidence
diff --git a/decision/taxonomy/thunderclap_headache/flows/clarify.yaml b/decision/taxonomy/thunderclap_headache/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..77a386a9c07a5bbd6c38cd3c5f4b23dcb06c3ed5
--- /dev/null
+++ b/decision/taxonomy/thunderclap_headache/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: thunderclap_headache
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: thunderclap_headache_clarify
+      goal: "Ask patient to describe their thunderclap headache symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - thunderclap_headache_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/thunderclap_headache/flows/escalate_r3.yaml b/decision/taxonomy/thunderclap_headache/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f340d4f4021536cfc8d46b25c98b8dda8c0d5189
--- /dev/null
+++ b/decision/taxonomy/thunderclap_headache/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: thunderclap_headache
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Inform patient this requires immediate clinical attention and they will be transferred"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/thunderclap_headache/flows/handoff.yaml b/decision/taxonomy/thunderclap_headache/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..56d7a5dda78a92754ad5bae87b19a3216a2eb292
--- /dev/null
+++ b/decision/taxonomy/thunderclap_headache/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: thunderclap_headache
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: thunderclap_headache_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: thunderclap_headache_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/thunderclap_headache/rules.yaml b/decision/taxonomy/thunderclap_headache/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d3f217c73d2e1d367af7259731c598ba841b3596
--- /dev/null
+++ b/decision/taxonomy/thunderclap_headache/rules.yaml
@@ -0,0 +1,21 @@
+domain: thunderclap_headache
+target_risk_class: R3
+
+decision_rules:
+  - id: thunderclap_headache_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r3
+
+  - id: thunderclap_headache_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r3
+
+  - id: thunderclap_headache_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/thunderclap_headache/triggers.yaml b/decision/taxonomy/thunderclap_headache/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c2cc658706dee9893e9a56c36185786ba2583e75
--- /dev/null
+++ b/decision/taxonomy/thunderclap_headache/triggers.yaml
@@ -0,0 +1,185 @@
+domain: thunderclap_headache
+priority: 89
+
+lexical_signals:
+  high:
+    phrases:
+      - "worst headache of my life"
+      - "sudden severe headache"
+      - "thunderclap headache"
+      - "head feels like it's exploding"
+      - "excruciating headache came on suddenly"
+      - "worst headache ever"
+      - "worst headache I've ever had"
+      - "explosive headache"
+      - "headache hit like a bolt"
+      - "sudden intense headache"
+    regex:
+      - "worst\\s+(headache|head\\s*ache|head\\s+pain)"
+      - "(sudden|instant|immediate|abrupt).{0,25}(headache|head\\s*ache|head\\s+pain)"
+      - "(headache|head\\s*ache|head\\s+pain).{0,25}(worst|terrible|excruciating|explosive|thunderclap|intense|severe)"
+      - "(headache|head\\s*ache).{0,20}(like a (bolt|switch|bomb|explosion))"
+      - "(headache|head\\s*ache|head).{0,20}(hit|struck|came on|started).{0,15}(sudden|instant|immediate|out of nowhere|fast)"
+      - "thunderclap"
+      - "\\bhead\\b.{0,10}(feels like|like).{0,10}(explod|split|burst|crack|gonna blow)"
+      - "\\bhead\\b.{0,10}(splitting|pounding|exploding|throbbing).{0,15}(never|worst|ever|so bad|terrible)"
+  medium:
+    phrases:
+      - "severe headache out of nowhere"
+      - "worst headache I've had"
+      - "headache hit suddenly and severely"
+      - "severe headache came on suddenly"
+      - "headache that peaked immediately"
+      - "headache like a switch flipped"
+      - "headache during exertion"
+      - "headache and stiff neck"
+      - "headache and vomiting"
+      - "headache with neck stiffness"
+      - "went from fine to worst headache"
+      - "headache hit out of nowhere"
+      - "headache and neck feels stiff"
+      - "really sudden headache"
+      # --- additional patterns ---
+      - "peaked immediately"
+      - "hit like lightning"
+      - "10 out of 10 within seconds"
+      - "never felt anything like this"
+      - "different from my migraines"
+      - "threw up from the pain"
+      - "neck is so stiff"
+      - "head felt like it popped"
+      - "worst pain of my life in my head"
+      # --- Phase 4: expanded patterns for missed scenarios ---
+      - "worst headache of my life"
+      - "head is exploding"
+      - "like a bomb went off"
+      - "screaming from the pain"
+      # --- sudden onset superlatives ---
+      - "worst pain I've ever felt"
+      - "worst pain of my life"
+      - "like nothing I've ever felt"
+      - "like nothing before"
+      - "never experienced anything like this"
+      - "I've never experienced anything like this"
+      - "I've never felt anything like this"
+      - "unlike anything I've felt"
+      - "completely different from"
+      - "this is different"
+      - "it's different from"
+      - "different from my usual"
+      # --- sudden onset descriptors ---
+      - "hit me like a truck"
+      - "hit like a truck"
+      - "like someone hit me"
+      - "like a baseball bat"
+      - "hit me with a hammer"
+      - "like a hammer"
+      - "like a switch flipped"
+      - "someone flipped a switch"
+      - "flipped a switch"
+      - "out of nowhere"
+      - "came out of nowhere"
+      - "came on so fast"
+      - "came on suddenly"
+      - "came on instantly"
+      - "pain was instantaneous"
+      - "pain was instant"
+      - "instant 10/10"
+      - "instant ten out of ten"
+      - "ten out of ten"
+      - "10/10"
+      - "just BAM"
+      - "then BAM"
+      - "and then boom"
+      - "suddenly boom"
+      # --- exertional onset ---
+      - "headache during sex"
+      - "headache while lifting"
+      - "while bending over"
+      - "while straining"
+      - "during deadlifts"
+      # --- associated symptoms with headache ---
+      - "stiff neck with headache"
+      - "neck stiff with this headache"
+      - "vomiting with this headache"
+      - "threw up with the headache"
+      # --- minimizer reversals ---
+      - "probably nothing but worst"
+      - "probably overreacting but worst"
+      - "don't want to overreact but worst"
+      - "don't want to be dramatic but"
+      - "scary different"
+    regex:
+      - "(headache|head\\s+pain).{0,30}(neck.{0,10}(stiff|tight|rigid)|stiff\\s+neck)"
+      - "(neck.{0,10}(stiff|tight|rigid)).{0,30}(headache|head\\s+pain)"
+      - "(headache|head\\s+pain|\\bhead\\b).{0,30}(vomit|threw up|nausea)"
+      - "(headache|head\\s+pain).{0,25}(exert|lift|strain|exercise|deadlift|workout)"
+      - "peak.{0,10}(immediate|instant|right away)"
+      - "(headache|head\\s+pain|head is).{0,25}(killing|splitting|pounding|crushing|unbearable)"
+      - "(never|worst|most).{0,15}(headache|head\\s+pain).{0,10}(ever|in my life|I've)"
+      # --- exertional onset ---
+      - "headache\\s+(during|while|when)\\s+(sex|lifting|straining|exertion|exercise|bending)"
+      # --- vomiting + headache ---
+      - "(projectile|started)\\s+vomiting\\s+(with|and)\\s+(this\\s+)?headache"
+      # --- never felt this ---
+      - "never\\s+(felt|had|experienced).{0,15}(anything|headache|pain).{0,10}(like this|this bad|this severe)"
+      # --- Phase 4: expanded patterns for missed scenarios ---
+      - "(he|she).{0,30}(scream|yell|cry).{0,20}(head|pain)"
+      - "(keep|keeps).{0,20}(say|saying).{0,30}(never|nothing|worst).{0,20}(felt|like)"
+      - "(hit|struck|smash).{0,15}(hammer|wall|freight|truck|bomb|bat)"
+      - "(can't|cannot).{0,20}(think|thought).{0,10}(straight|together|clearly)"
+      - "threw up.{0,30}(minute|min|second|after).{0,15}headache"
+      - "headache.{0,30}threw up"
+      # --- superlative after minimization ---
+      - "(just|probably|could be).{0,30}(worst|never\\s+felt|most\\s+severe)"
+      # --- minimization then sudden onset ---
+      - "(headache|just\\s+headache).{0,30}(usual|sometimes|nothing).{0,30}(sudden|quick|fast)"
+      # --- sudden onset superlative patterns ---
+      - "(worst|most\\s+severe|terrible).{0,15}(pain|headache).{0,15}(ever|of my life|I'?ve)"
+      - "like\\s+nothing.{0,15}(I'?ve|before|ever)"
+      - "unlike\\s+(anything|any).{0,15}(I'?ve|before|ever)"
+      - "(completely|totally|entirely)\\s+different\\s+from"
+      # --- sudden onset impact descriptors ---
+      - "(hit|struck).{0,10}(me|him|her).{0,10}(like\\s+a|with\\s+a).{0,10}(truck|hammer|bat|bolt)"
+      - "like\\s+(someone|a).{0,10}(hit|struck).{0,10}(me|my head)"
+      - "(like\\s+)?a\\s+(switch|bolt|bomb|hammer|truck|baseball bat)"
+      - "(flipped|flip).{0,10}(a\\s+)?switch"
+      - "(out of|outta)\\s+nowhere"
+      - "came\\s+(on|out).{0,10}(so\\s+)?(fast|suddenly|instantly|quick)"
+      # --- instant severity ---
+      - "(pain|headache).{0,10}(was|is).{0,10}(instantaneous|instant|immediate)"
+      - "instant.{0,10}(10|ten).{0,5}(/|out of).{0,5}(10|ten)"
+      - "(10|ten).{0,5}(/|out of).{0,5}(10|ten)"
+      - "(BAM|boom|bam|BOOM)"
+      # --- exertional onset patterns ---
+      - "headache.{0,15}(during|while|when).{0,10}(sex|lifting|straining|bending|deadlift)"
+      - "(while|when|during).{0,10}(bending|lifting|straining|exert).{0,20}headache"
+      # --- associated symptoms patterns ---
+      - "(stiff|tight)\\s+neck.{0,20}(headache|head\\s+pain|this)"
+      - "(my\\s+)?neck.{0,10}(feels|is).{0,10}(stiff|tight|rigid).{0,20}headache"
+      - "(threw up|vomit|nausea).{0,20}(headache|head\\s+pain|this)"
+      # --- minimizer reversal patterns ---
+      - "(probably|don'?t want to).{0,20}(overreact|dramatic|nothing).{0,20}(but|worst|terrible|severe)"
+      - "(scary|scaring).{0,10}different"
+      - "(know|sure).{0,10}(sounds|seems).{0,10}(serious|bad)"
+  low:
+    partials:
+      - "thunderclap"
+      - "subarachnoid"
+      - "worst headache"
+      - "sudden headache"
+      - "severe headache"
+
+negation_handling:
+  patterns:
+    - "headache is gone"
+    - "no headache"
+    - "headache resolved"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/tobacco_use_active/flows/cessation_resources.yaml b/decision/taxonomy/tobacco_use_active/flows/cessation_resources.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..afd114ea8bae23d40211b7711030466bdf8abf08
--- /dev/null
+++ b/decision/taxonomy/tobacco_use_active/flows/cessation_resources.yaml
@@ -0,0 +1,23 @@
+flow_id: cessation_resources
+type: resolution
+domain: tobacco_use_active
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: tobacco_cessation_resources
+      goal: "Offer cessation resources in a supportive, non-judgmental way. Inform care team will follow up."
+      tone: warm_supportive
+      must_include:
+        - "care team"
+        - "resources"
+      must_not:
+        - "bad habit"
+        - "you need to quit"
+        - "you should stop"
+        - "lecture"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/tobacco_use_active/flows/clarify.yaml b/decision/taxonomy/tobacco_use_active/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f2d07bdc646ff3a6345c59324693656427a069cb
--- /dev/null
+++ b/decision/taxonomy/tobacco_use_active/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: tobacco_use_active
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: tobacco_clarify
+      goal: "Ask the patient to tell more about their tobacco or nicotine use"
+      tone: warm_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "bad habit"
+        - "you should quit"
+      max_questions: 1
+    collects:
+      - tobacco_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/tobacco_use_active/flows/tobacco_assessment.yaml b/decision/taxonomy/tobacco_use_active/flows/tobacco_assessment.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7dbcf12732e5da85eb28ccca09fc7ecc3e414cc9
--- /dev/null
+++ b/decision/taxonomy/tobacco_use_active/flows/tobacco_assessment.yaml
@@ -0,0 +1,54 @@
+flow_id: tobacco_assessment
+type: assessment
+domain: tobacco_use_active
+
+required_slots:
+  - tobacco_type
+  - tobacco_frequency
+  - quit_interest
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: tobacco_assess_step1
+      goal: "Assess the type and frequency of tobacco or nicotine use"
+      tone: warm_professional
+      must_include:
+        - "tobacco"
+      must_ask:
+        - "What type of tobacco or nicotine product do you use?"
+        - "About how often do you use it?"
+      must_not:
+        - "bad habit"
+        - "shouldn't"
+        - "lecture"
+      max_questions: 2
+    collects:
+      - tobacco_type
+      - tobacco_frequency
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: tobacco_assess_step2
+      goal: "Assess whether the patient has interest in quitting or reducing use"
+      tone: warm_professional
+      must_include:
+        - "quit"
+      must_ask:
+        - "Have you thought about cutting back or quitting?"
+      must_not:
+        - "you should quit"
+        - "bad for you"
+        - "lecture"
+        - "judgmental"
+      max_questions: 1
+    collects:
+      - quit_interest
+
+exit:
+  on_complete: evaluate_concern
+  on_concern: cessation_resources
+  on_low_risk: cessation_resources
+  on_unclear: cessation_resources
diff --git a/decision/taxonomy/tobacco_use_active/rules.yaml b/decision/taxonomy/tobacco_use_active/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6da386f27708d49bac2a378ce033f2d11fb57c1b
--- /dev/null
+++ b/decision/taxonomy/tobacco_use_active/rules.yaml
@@ -0,0 +1,21 @@
+domain: tobacco_use_active
+target_risk_class: R0
+
+decision_rules:
+  - id: tobacco_use_active_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: tobacco_assessment
+
+  - id: tobacco_use_active_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: tobacco_assessment
+
+  - id: tobacco_use_active_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/tobacco_use_active/triggers.yaml b/decision/taxonomy/tobacco_use_active/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..72e1dee945691099b623be974807fb7622bb91a4
--- /dev/null
+++ b/decision/taxonomy/tobacco_use_active/triggers.yaml
@@ -0,0 +1,75 @@
+domain: tobacco_use_active
+priority: 25
+
+lexical_signals:
+  high:
+    phrases:
+      - "still smoking a pack a day"
+      - "smoking more than ever"
+      - "can't quit smoking"
+      - "vaping all day long"
+      - "chewing tobacco every day"
+      - "smoke two packs a day"
+      - "been smoking for years and can't stop"
+      - "addicted to cigarettes"
+      - "addicted to nicotine"
+      - "chain smoking"
+      - "go through a pack a day"
+      - "smoking since I was a teenager"
+      - "tried to quit smoking but can't"
+      - "heavy smoker"
+      - "vaping constantly"
+    regex:
+      - "(still|keep|can't\\s+stop|can't\\s+quit).{0,10}(smoking|vaping|using\\s+tobacco|chewing)"
+      - "(pack|packs)\\s+(a|per|every)\\s+day"
+      - "(addicted|dependent|hooked).{0,10}(cigarette|nicotine|tobacco|vaping)"
+      - "(heavy|chain).{0,5}(smok|vap)"
+  medium:
+    phrases:
+      - "still smoking"
+      - "I smoke"
+      - "vaping"
+      - "cigarettes"
+      - "nicotine"
+      - "chewing tobacco"
+      - "e-cigarette"
+      - "pack a day"
+      - "smoke a few cigarettes"
+      - "use nicotine"
+      - "smoking on and off"
+      - "social smoker"
+      - "have a cigarette"
+      - "smoke occasionally"
+      - "dip tobacco"
+    regex:
+      - "(still|currently|do|am)\\s+(smok|vap|using\\s+tobacco|chewing)"
+      - "(cigarette|nicotine|tobacco|e-cigarette|vape).{0,10}(use|user|every|daily)"
+  low:
+    partials:
+      - "smoke"
+      - "cigarette"
+      - "nicotine"
+      - "vape"
+      - "tobacco"
+
+negation_handling:
+  patterns:
+    - "i quit smoking"
+    - "stopped smoking"
+    - "don't smoke"
+    - "gave up cigarettes"
+    - "no longer smoking"
+    - "kicked the habit"
+    - "smoke free"
+    - "not a smoker"
+    - "i quit vaping"
+    - "don't vape"
+    - "never smoked"
+    - "don't use tobacco"
+    - "quit years ago"
+    - "haven't smoked in"
+    - "stopped using nicotine"
+    - "tobacco free"
+    - "gave up tobacco"
+    - "clean for years"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/uncontrolled_pain/flows/clarify.yaml b/decision/taxonomy/uncontrolled_pain/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..cf3de1a50dee85d69f01b3cea3f23373a1106306
--- /dev/null
+++ b/decision/taxonomy/uncontrolled_pain/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: uncontrolled_pain
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: uncontrolled_pain_clarify
+      goal: "Ask patient to describe their uncontrolled pain symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - uncontrolled_pain_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/uncontrolled_pain/flows/escalate_r2.yaml b/decision/taxonomy/uncontrolled_pain/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ae02750447b75a65f95b4e6292fd797eac9e4b11
--- /dev/null
+++ b/decision/taxonomy/uncontrolled_pain/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: uncontrolled_pain
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/uncontrolled_pain/flows/handoff.yaml b/decision/taxonomy/uncontrolled_pain/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..808fa09a2fdcd06b7f716433c18a19c3be380366
--- /dev/null
+++ b/decision/taxonomy/uncontrolled_pain/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: uncontrolled_pain
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: uncontrolled_pain_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: uncontrolled_pain_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/uncontrolled_pain/flows/safety_screen.yaml b/decision/taxonomy/uncontrolled_pain/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..070fd2d6e44c35928191d18b5381e01ddedde4ab
--- /dev/null
+++ b/decision/taxonomy/uncontrolled_pain/flows/safety_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: safety_screen
+type: screening
+domain: uncontrolled_pain
+
+required_slots:
+  - pain_severity
+  - pain_location
+  - medications_tried
+  - pain_duration
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "pain severity"
+        - "pain location"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - pain_severity
+      - pain_location
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "medications tried"
+        - "pain duration"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - medications_tried
+      - pain_duration
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/decision/taxonomy/uncontrolled_pain/rules.yaml b/decision/taxonomy/uncontrolled_pain/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..269dc4ce56bbd9c65fa5126392458df16a15e916
--- /dev/null
+++ b/decision/taxonomy/uncontrolled_pain/rules.yaml
@@ -0,0 +1,27 @@
+domain: uncontrolled_pain
+target_risk_class: R2
+
+decision_rules:
+  - id: uncontrolled_pain_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: uncontrolled_pain_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: uncontrolled_pain_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: uncontrolled_pain_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/uncontrolled_pain/triggers.yaml b/decision/taxonomy/uncontrolled_pain/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..dd66c6307f10c8fde4ffb72f8450bc3c377bd38c
--- /dev/null
+++ b/decision/taxonomy/uncontrolled_pain/triggers.yaml
@@ -0,0 +1,227 @@
+domain: uncontrolled_pain
+priority: 70
+
+lexical_signals:
+  high:
+    phrases:
+      - "pain is out of control"
+      - "pain is 10 out of 10"
+      - "unbearable pain despite medication"
+      - "worst pain of my life"
+      - "it barely touched it"
+      - "in a lot of pain and I can't get it under control"
+      - "pain medication is not doing anything"
+      - "I took my pills and it did nothing"
+      - "screaming in pain"
+      - "crying from the pain"
+      - "the pain is so bad I can't move"
+      - "I can't take this pain anymore"
+      - "nothing is touching this pain"
+      - "been in agony all day"
+      - "pain is absolutely unbearable"
+      - "doubled over in pain"
+      - "I want to go to the ER for the pain"
+      - "pain has me in tears"
+    regex:
+      - "pain.*out\\s+of\\s+control"
+      - "pain.*10\\s*(out\\s+of|/)\\s*10"
+      - "pain.*(won[']?t|doesn[']?t|didn[']?t)\\s+(stop|quit|go away|let up|settle)"
+      - "(took|tried|take|taken).*(ibuprofen|tylenol|advil|acetaminophen|medication|pills?|meds?|oxycodone|percocet|norco|vicodin|tramadol|hydrocodone).*(didn[']?t|not|barely|won[']?t|doesn[']?t)\\s*(help|work|touch|do)"
+      - "(can[']?t|unable\\s+to)\\s+(get\\s+)?comfort"
+      - "medication\\s+isn[']?t\\s+touch"
+      - "pain\\s+(that\\s+)?won[']?t\\s+quit"
+      - "pain\\s+won[']?t\\s+stop"
+      - "(scream|cry|sob|moan|groan|wail|holler|yell).{0,10}(from|in|with|because).{0,10}(the\\s+)?pain"
+      - "pain.{0,15}(scream|cry|sob|moan|groan|wail|holler|yell)"
+      - "(can[']?t|unable).{0,5}(to\\s+)?(take|stand|handle|bear|tolerate|endure).{0,10}(this\\s+|the\\s+)?pain"
+      - "nothing.{0,10}(is\\s+)?(touch|help|work).{0,5}(ing|s)?.{0,10}(this\\s+|the\\s+)?pain"
+      - "pain.{0,10}(so\\s+bad|terrible|horrible|excruciating|agonizing)"
+      - "(doubled|curled|bent).{0,5}(over|up).{0,10}(in\\s+|from\\s+|with\\s+)?pain"
+      - "want.{0,10}(go\\s+to|visit).{0,10}(the\\s+)?(ER|emergency|hospital).{0,10}(for\\s+)?(the\\s+)?pain"
+      - "pain.{0,10}(has|got|have).{0,5}me.{0,5}(in\\s+)?tears"
+  medium:
+    phrases:
+      - "still in a lot of pain"
+      - "pain is getting worse"
+      - "pain keeps increasing"
+      - "intense pain"
+      - "8 out of 10"
+      - "9 out of 10"
+      - "guarding and moving slow"
+      - "in a lot of pain"
+      - "everything hurts"
+      - "this awful hurting"
+      - "pain woke me up in the middle of the night"
+      - "can't get comfortable no matter what I do"
+      - "I have tried everything for this pain"
+      - "took extra pills and it still hurts"
+      - "the pain keeps coming back stronger"
+      - "hurting way more than yesterday"
+      - "pain is spreading"
+      - "my whole body aches"
+      - "I can't even sit still the pain is so bad"
+      - "I have not slept in two days from the pain"
+      - "the medicine only takes the edge off"
+      - "it helps for maybe an hour then comes right back"
+      - "the pain is making me sick to my stomach"
+      - "rated my pain a nine"
+      - "throbbing non stop"
+      # --- MINIMIZER coverage ---
+      - "pain isn't that bad really"
+      - "I can handle it, it's just annoying"
+      - "probably just need to rest"
+      - "it's there but I'm managing"
+      - "just a bit of pain"
+      - "discomfort more than pain"
+      - "it's bearable"
+      - "not terrible but it won't go away"
+      - "pain comes and goes, probably nothing"
+      # --- additional patterns ---
+      - "pain is making me throw up"
+      - "can't function because of the pain"
+      - "I haven't eaten because of the pain"
+      - "pain keeps me up all night"
+      # --- Phase 6: R2 recall expansion ---
+      - "pain is unbearable"
+      - "can't take it anymore"
+      - "nothing touches the pain"
+      - "worst pain ever"
+      - "pain making me cry"
+    regex:
+      - "pain\\s+isn[']?t\\s+(getting\\s+)?better"
+      - "pain\\s+medication\\s+not\\s+working"
+      - "can[']?t\\s+manage\\s+the\\s+pain"
+      - "(hurting|pain).{0,30}(a\\s+lot|really|so)\\s*(bad|much|intense)?"
+      - "pain.*([89]|eight|nine)\\s*(out\\s+of|/)\\s*10"
+      - "pain.*(spike|spikes|spiking|waves?)"
+      - "(pain|hurt|ache|sore|throb).{0,40}(can[']?t|unable)\\s+(sleep|focus|sit|eat|work|calm|function|concentrate|think)"
+      - "(can[']?t|unable)\\s+(sleep|focus|sit|eat|work|calm|function|concentrate|think).{0,40}(pain|hurt|ache|sore|throb|because of|from the|due to)"
+      - "keep\\s+(pacing|shifting|moving)"
+      - "it[']?s\\s+messing\\s+with"
+      - "making\\s+me\\s+snappy"
+      - "can[']?t\\s+focus\\s+on\\s+anything"
+      - "can[']?t\\s+sleep"
+      - "(just|really)\\s+(hurting|uncomfortable)"
+      - "hurting\\s+(a\\s+lot|bad|so)"
+      - "hard\\s+to\\s+manage"
+      - "pain\\s+thing"
+      - "this\\s+pain"
+      - "just\\s+this\\s+pain"
+      - "(snappy|irritable|cranky).*pain"
+      - "pain.*(snappy|irritable|cranky)"
+      - "it\\s+spikes"
+      - "can[']?t\\s+get\\s+comfy"
+      - "hurts\\s+(so|really|a\\s+lot|bad|worse|terribly|horribly)"
+      - "keeps?\\s+interrupting"
+      - "annoying\\s+pain"
+      - "(lack|loss)\\s+of\\s+sleep"
+      - "irritable.*sleep"
+      - "sleep.*irritable"
+      - "(area|whole|entire|every)\\s+hurts"
+      - "pain.{0,10}(woke|wake).{0,5}(me\\s+)?up"
+      - "(woke|wake).{0,10}up.{0,10}(from|with|because).{0,10}pain"
+      - "tried\\s+everything.{0,10}(for\\s+)?(the\\s+)?pain"
+      - "(took|take|taking)\\s+(extra|more|double|two|another).{0,10}(pill|med|dose|tablet)"
+      - "pain.{0,10}(com|keep|came|keeps).{0,10}(back|return)"
+      - "(worse|more|bad).{0,5}(than|er).{0,10}yesterday"
+      - "pain.{0,10}(spread|radiat|mov)"
+      - "(whole|entire)\\s+(body|side).{0,10}(ache|hurt|pain)"
+      - "(medicine|med|pill|medication).{0,10}(only|just|barely).{0,10}(take|help)"
+      - "(help|work|last).{0,10}(for\\s+)?(maybe\\s+)?(an\\s+hour|a\\s+bit|a\\s+little).{0,10}(then|and|but)"
+      - "pain.{0,10}(mak|made).{0,10}(me\\s+)?(sick|nauseous|throw|vomit)"
+      - "(throb|puls|pound).{0,5}(ing|s).{0,10}(non\\s*stop|constant|all\\s+day|all\\s+night)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(just|only).{0,10}(a\\s+)?(little|bit|slight|annoying|nagging).{0,10}(pain|ache|hurt|discomfort|sore)"
+      - "(pain|hurt|ache|sore).{0,15}(not that bad|bearable|manageable|tolerable|I can handle).{0,15}(but|though|just|won't)"
+      - "(pain|hurt|ache).{0,15}(won't|doesn't|not|never).{0,10}(go away|stop|let up|ease|quit|improve|subside)"
+      - "(probably|might be).{0,10}(just|nothing|need to rest|normal|muscle).{0,15}(pain|hurt|ache|sore)"
+      - "(discomfort|uncomfortable).{0,10}(more than|rather than|not really|wouldn't call it).{0,10}(pain|sharp|severe)"
+      # --- Low-literacy minimization patterns (R2 recall) ---
+      - "(not terrible|not that bad|nothing crazy).{0,15}(or anything|really|but)"
+      - "(back|hip|knee|shoulder|neck)\\s+thing.{0,15}(going on|bothering|acting up)"
+      - "(just|kind of|sort of)\\s+(bugging|bothering|nagging|annoying)\\s+me"
+      # --- Duration + minimization ---
+      - "(pain|hurt|ache).{0,30}(days?|weeks?|since).{0,20}(not bad|manage|handle|ice|heat|rest)"
+      - "(been|going on).{0,15}(days?|weeks?|while).{0,20}(not that bad|can handle|manage)"
+      # --- Functional impact patterns ---
+      - "(can't|unable to|hard to).{0,10}(do what I used to|do my usual|do things)"
+      - "(affecting|impacts?|interfering).{0,15}(my work|my job|daily|sleep|life)"
+      - "(hard|difficult|tough|struggling).{0,10}(to sleep|sleeping|to rest)"
+      - "(keeping|waking|wake).{0,10}(me up|up at night|me at night)"
+      # --- Phase 6: R2 recall expansion ---
+      - "pain.{0,20}(unbearable|intolerable|excruciating|can't take|can't stand)"
+      - "(nothing|meds|medication|pills).{0,20}(touch|help|work).{0,15}(the )?pain"
+      - "pain.{0,20}(making|makes).{0,10}(me )?(cry|scream|vomit|pass out)"
+      - "(worst|severe|extreme).{0,10}pain.{0,20}(ever|of my life|I've had)"
+  low:
+    partials:
+      - "uncontrolled pain"
+      - "pain worse"
+      - "pain not managed"
+      - "really hurting"
+      - "agony"
+      - "meds not working"
+      - "nothing helps"
+      - "excruciating"
+      - "hurting a lot"
+      - "pain spikes"
+      - "just hurting"
+      - "keep pacing"
+      - "uncomfortable"
+      - "throbbing"
+      - "can't sleep"
+      - "constant pain"
+      - "severe pain"
+      - "pills not working"
+      - "breakthrough pain"
+      - "writhing"
+
+negation_handling:
+  patterns:
+    - "pain is controlled"
+    - "medication is working"
+    - "pain is manageable"
+    - "pain is better"
+    - "pain went down"
+    - "pain is much better now"
+    - "the medication helped"
+    - "pain is under control"
+    - "feeling better after taking my meds"
+    - "pain went from a nine to a three"
+    - "manageable now"
+    - "the pain finally broke"
+    - "not in pain anymore"
+    - "pain free"
+    - "no pain at the moment"
+    - "comfortable right now"
+    - "pain has been fine"
+    - "meds are working great"
+    - "took my pills and it helped"
+    - "pain only when I move a certain way"
+    - "just a little sore"
+    - "mild discomfort"
+    - "it is just muscle soreness"
+    # --- worsening_chronic_pain (R1) routine context ---
+    - "chronic pain"
+    - "chronic back pain"
+    - "chronic lower back"
+    - "herniated disc"
+    - "flare-up"
+    - "flare up"
+    - "my usual pain"
+    - "my regular pain"
+    - "my baseline"
+    - "instead of my usual"
+    - "physical therapy"
+    - "PT referral"
+    - "pain management plan"
+    - "pain management appointment"
+    - "managing my pain"
+    - "been dealing with this for"
+    - "had this for years"
+    - "out of 10 instead of"
+    - "3 or 4 out of 10"
+    - "4 out of 10"
+    - "5 out of 10"
+    - "6 out of 10"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/urinary_retention/flows/clarify.yaml b/decision/taxonomy/urinary_retention/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c64092910547d12d444e5dbb2e510d2ac160938f
--- /dev/null
+++ b/decision/taxonomy/urinary_retention/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: urinary_retention
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: urinary_retention_clarify
+      goal: "Ask patient to describe their urinary retention symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - urinary_retention_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/urinary_retention/flows/escalate_r2.yaml b/decision/taxonomy/urinary_retention/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..34a0263bf5bd2667ec8f59b7a369a9fdc8659839
--- /dev/null
+++ b/decision/taxonomy/urinary_retention/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: urinary_retention
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/urinary_retention/flows/handoff.yaml b/decision/taxonomy/urinary_retention/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e183da7d716417e45a79d10d720ca51ecd467368
--- /dev/null
+++ b/decision/taxonomy/urinary_retention/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: urinary_retention
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: urinary_retention_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: urinary_retention_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/urinary_retention/flows/safety_screen.yaml b/decision/taxonomy/urinary_retention/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5953f79ae9b89da169692bb2a33d25656c70d5e1
--- /dev/null
+++ b/decision/taxonomy/urinary_retention/flows/safety_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: safety_screen
+type: screening
+domain: urinary_retention
+
+required_slots:
+  - last_urination
+  - bladder_fullness
+  - pain_severity
+  - fluid_intake
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "last urination"
+        - "bladder fullness"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - last_urination
+      - bladder_fullness
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "pain severity"
+        - "fluid intake"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - pain_severity
+      - fluid_intake
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/decision/taxonomy/urinary_retention/rules.yaml b/decision/taxonomy/urinary_retention/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8dc4411ac4515098677e7a7d40319e9739ee8c5e
--- /dev/null
+++ b/decision/taxonomy/urinary_retention/rules.yaml
@@ -0,0 +1,27 @@
+domain: urinary_retention
+target_risk_class: R2
+
+decision_rules:
+  - id: urinary_retention_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: urinary_retention_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: urinary_retention_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: urinary_retention_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/urinary_retention/triggers.yaml b/decision/taxonomy/urinary_retention/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0ffcd86e2dd1f16c97b053ac40de1760834a8a2d
--- /dev/null
+++ b/decision/taxonomy/urinary_retention/triggers.yaml
@@ -0,0 +1,202 @@
+domain: urinary_retention
+priority: 66
+
+lexical_signals:
+  high:
+    phrases:
+      - "acute urinary retention"
+      - "unable to pass urine"
+      - "blocked bladder"
+      - "can't pee at all"
+      - "haven't urinated all day"
+      - "haven't been able to pee since yesterday"
+      - "nothing comes out when I try to pee"
+      - "I sit there and nothing happens"
+      - "bladder feels like it is going to burst"
+      - "can't urinate and my belly is swollen"
+      - "I have not peed in over twelve hours"
+      - "tried everything and I still can't go"
+      - "bladder is full but nothing comes out"
+      - "it won't come out no matter how hard I push"
+      - "completely unable to void"
+      - "I need a catheter I can't pee"
+      - "belly is huge and hard and I can't urinate"
+    regex:
+      - "can[']?t\\s+(urinat|pee|void)"
+      - "(urinary|bladder)\\s+retention"
+      - "(haven[']?t|hasn[']?t|not)\\s+(pee|urinate|gone)d?\\s+(since|in|for|all)"
+      - "nothing\\s+(comes?|came?)\\s+out"
+      - "(can[']?t|won[']?t|unable)\\s+(to\\s+)?(pee|urinate|go|void)"
+      - "(lower\\s+)?(bell?y|abdomen|stomach)\\s+(feel|is)s?\\s+(really\\s+)?(full|tight|swollen|bloated|pressurized)"
+      - "it\\s+won[']?t\\s+start"
+      - "can[']?t\\s+pee"
+      - "haven[']?t\\s+peed"
+      - "(haven[']?t|hasn[']?t|not).{0,10}(pee|urinat|void|gone).{0,10}(in\\s+)?(over\\s+)?(\\d+|twelve|eight|ten|six|twenty)\\s*(hour|hr)"
+      - "bladder.{0,10}(burst|explod|pop|about\\s+to)"
+      - "(complete|total)ly\\s+unable\\s+to\\s+(pee|urinat|void|go)"
+      - "need\\s+a\\s+catheter"
+      - "(belly|abdomen|stomach).{0,10}(huge|hard|distend|swollen).{0,15}(can[']?t|unable|won[']?t).{0,10}(pee|urinat|void)"
+      - "nothing.{0,10}(come|happen|start).{0,10}(out|when|no\\s+matter)"
+  medium:
+    phrases:
+      - "difficulty urinating"
+      - "very hard to urinate"
+      - "barely any urine output"
+      - "straining to urinate"
+      - "urinary retention symptoms"
+      - "not able to empty bladder"
+      - "only a few drops"
+      - "just a dribble"
+      - "a teaspoon and it stops"
+      - "body forgot what to do"
+      - "it burned a bit then nothing"
+      - "tiny dribble"
+      - "maybe a few drops then nothing"
+      - "I keep going to the bathroom but barely anything comes out"
+      - "feels like I need to go but I can't"
+      - "sitting on the toilet for twenty minutes and nothing"
+      - "running the water and it still won't come"
+      - "pushing as hard as I can and only drops come out"
+      - "stream starts and stops right away"
+      - "urine is just trickling"
+      - "had to push really hard just to get a little out"
+      - "my belly is so full and uncomfortable"
+      - "lower belly is really tight and I can't go"
+      - "had the catheter out and now I can't pee on my own"
+      - "since the anesthesia I can't pee right"
+      - "been trying to go all morning"
+      - "pressure down there like I have to go but nothing comes"
+      # --- MINIMIZER coverage ---
+      - "having a bit of trouble going"
+      - "stream isn't quite right"
+      - "just takes longer to get started"
+      - "probably just dehydrated"
+      - "not going as often as I should"
+      - "it's a bit uncomfortable down there"
+      - "can't quite empty my bladder"
+      - "peeing is a bit off"
+      # --- additional patterns ---
+      - "bladder hurts so bad"
+      - "painful pressure down there"
+      - "leaking but can't empty"
+      - "dribbling but feels full"
+      - "stomach is huge and tight"
+      - "since I started my new meds"
+      - "my retention is back"
+    regex:
+      - "(only|just|maybe)\\s+(a\\s+)?(few|tiny|little|couple)\\s+(drops?|dribble|trickle|bit)"
+      - "keep\\s+(going|running)\\s+(back\\s+)?(to\\s+)?the\\s+bathroom"
+      - "(body|it).*(won[']?t|forgot|refuse|doesn[']?t)\\s+(cooperate|work|go|start)"
+      - "(pee|urinat|void).*(barely|hardly|little|almost nothing)"
+      - "(strain|push|trying|sit).{0,20}(to\\s+)?(pee|urinate|void)"
+      - "can[']?t\\s+(pee|go)\\s+(normally|properly|right)"
+      - "feels?\\s+like\\s+I\\s+should\\s+be\\s+able\\s+to\\s+go"
+      - "lower\\s+(belly|back)\\s+(hurts?|pain|ache|tight)"
+      - "something[']?s\\s+off\\s+when\\s+I\\s+try\\s+to\\s+pee"
+      - "body\\s+won[']?t\\s+cooperate"
+      - "taking\\s+forever\\s+in.*bathroom"
+      - "trouble\\s+when\\s+I\\s+go\\s+to\\s+pee"
+      - "having\\s+trouble.*pee"
+      - "can[']?t\\s+go\\s+normally"
+      - "(lower\\s+)?(bell?y|abdomen).*(pressur|full|tight|bloat)"
+      - "not\\s+passing\\s+much"
+      - "can[']?t\\s+pee\\s+properly"
+      - "odd.*(not|aren[']?t)\\s+passing"
+      - "(uncomfortable|discomfort).*(down\\s+there|lower)"
+      - "(sit|sitting).{0,10}(on\\s+)?(the\\s+)?toilet.{0,10}(for\\s+)?(\\d+|twenty|thirty|fifteen|ten)\\s*(minute|min)"
+      - "(running|turn|ran).{0,10}(the\\s+)?(water|faucet|tap).{0,15}(still|won[']?t|can[']?t)"
+      - "stream.{0,10}(start|stop|weak|thin|slow|dribbl)"
+      - "(push|strain|bear).{0,10}(hard|down|really).{0,15}(drop|little|trickle|dribble)"
+      - "(catheter|cath).{0,10}(out|remov|taken).{0,15}(can[']?t|unable|won[']?t|not).{0,10}(pee|urinat|void|go)"
+      - "(anesthe|surgery|procedure|operation).{0,15}(can[']?t|unable|won[']?t).{0,10}(pee|urinat|void|go)"
+      - "(trying|been\\s+trying).{0,10}(to\\s+)?(go|pee|urinat).{0,10}(all\\s+)?(morning|day|night|afternoon|evening)"
+      - "pressure.{0,10}(down\\s+there|below|lower).{0,15}(have\\s+to\\s+go|need\\s+to\\s+go|nothing)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(just|only).{0,10}(a\\s+)?(little|bit|slight).{0,10}(trouble|hard|difficult).{0,10}(pee|urinat|go|void|empty)"
+      - "(probably|might be).{0,10}(just|nothing|dehydrat|normal).{0,20}(pee|urinat|bladder|go)"
+      - "(stream|flow|pee|urine).{0,15}(weak|slow|not quite|a bit|kind of|trickle|dribble|not right)"
+      - "(body|bladder).{0,15}(forgot|won't|not|can't).{0,10}(cooperat|work|go|empty|void|do)"
+      - "(can't\\s+quite|not\\s+really|having trouble).{0,15}(empty|void|go|pee|urinate|finish)"
+      # --- neurological cause ---
+      - "(back|spinal)\\s+(surgery|injury|problem)\\s+(and|now)\\s+(can'?t|unable|trouble)\\s+(pee|urinate|go)"
+      # --- medication cause ---
+      - "(started|new|changed)\\s+(my\\s+)?(meds?|medication|pills?).{0,20}(can'?t|trouble|unable|hard)\\s+(pee|urinat|void|go)"
+  low:
+    partials:
+      - "urinary retention"
+      - "blocked urine"
+      - "dribble"
+      - "belly full"
+      - "bladder pressure"
+      - "bathroom and nothing happens"
+      - "can't void"
+      - "weak stream"
+      - "slow stream"
+      - "hesitancy"
+      - "urinary difficulty"
+      - "straining"
+      - "incomplete emptying"
+      - "post-void fullness"
+
+negation_handling:
+  patterns:
+    - "urinating fine"
+    - "no urinary problems"
+    - "bladder emptying okay"
+    - "peeing normally"
+    - "urine flow is fine"
+    - "able to pee on my own now"
+    - "started peeing again"
+    - "bladder is emptying fine"
+    - "voiding without difficulty"
+    - "stream is back to normal"
+    - "peeing like normal"
+    - "no trouble urinating"
+    - "catheter is out and I am going fine"
+    - "went to the bathroom no problem"
+    - "urine output is good"
+    - "passing urine without issues"
+    - "no retention"
+    - "no difficulty voiding"
+    - "bladder feels empty after going"
+    - "just a little slow but it comes out fine"
+    # --- chronic back pain context (R1 scenarios) ---
+    - "chronic lower back"
+    - "chronic back pain"
+    - "chronic back"
+    - "lower back pain"
+    - "back pain for years"
+    - "back pain for months"
+    - "back pain for weeks"
+    - "back pain that"
+    - "back pain management"
+    - "physical therapy for my back"
+    - "PT for my back"
+    - "herniated disc"
+    - "bulging disc"
+    - "degenerative disc"
+    - "spinal stenosis"
+    - "sciatica"
+    - "my back has been"
+    - "back issue"
+    - "back problem"
+    - "back acting up"
+    - "my usual back"
+    # --- incontinence context (R1 post_procedure_incontinence) ---
+    - "leaking urine"
+    - "urine leakage"
+    - "incontinence"
+    - "leaking when I cough"
+    - "leaking when I sneeze"
+    - "leaking when I stand"
+    - "stress incontinence"
+    - "wearing pads"
+    - "pad changes"
+    - "leaking since surgery"
+    - "leaking since the procedure"
+    - "pelvic floor exercises"
+    - "pelvic floor"
+    - "Kegel"
+    - "kegels"
+    - "bladder control issue"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/worsening_chronic_pain/flows/clarify.yaml b/decision/taxonomy/worsening_chronic_pain/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e586691df6fb865e0ba5aef70f9cc8308c1d3134
--- /dev/null
+++ b/decision/taxonomy/worsening_chronic_pain/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: worsening_chronic_pain
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: worsening_chronic_pain_clarify
+      goal: "Ask patient to describe their worsening chronic pain symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - worsening_chronic_pain_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/worsening_chronic_pain/flows/escalate_r1.yaml b/decision/taxonomy/worsening_chronic_pain/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..813c766a9de4c68acc9619258055c2e49f61225b
--- /dev/null
+++ b/decision/taxonomy/worsening_chronic_pain/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: worsening_chronic_pain
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/worsening_chronic_pain/flows/handoff.yaml b/decision/taxonomy/worsening_chronic_pain/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c842dcf28df38fbc513603d7d8f369da7c9e91ea
--- /dev/null
+++ b/decision/taxonomy/worsening_chronic_pain/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: worsening_chronic_pain
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: worsening_chronic_pain_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: worsening_chronic_pain_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/worsening_chronic_pain/rules.yaml b/decision/taxonomy/worsening_chronic_pain/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d476a43b4973a0646b79dc965af7217491142004
--- /dev/null
+++ b/decision/taxonomy/worsening_chronic_pain/rules.yaml
@@ -0,0 +1,21 @@
+domain: worsening_chronic_pain
+target_risk_class: R1
+
+decision_rules:
+  - id: worsening_chronic_pain_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r1
+
+  - id: worsening_chronic_pain_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r1
+
+  - id: worsening_chronic_pain_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/worsening_chronic_pain/triggers.yaml b/decision/taxonomy/worsening_chronic_pain/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d29243ac6ac203b8cf530a5f79e1fe5e22790a59
--- /dev/null
+++ b/decision/taxonomy/worsening_chronic_pain/triggers.yaml
@@ -0,0 +1,34 @@
+domain: worsening_chronic_pain
+priority: 46
+
+lexical_signals:
+  high:
+    phrases:
+      - "chronic pain getting worse"
+      - "pain has been increasing steadily"
+      - "pain level going up despite treatment"
+      - "pain worse than before discharge"
+      - "chronic pain flare-up"
+      - "pain management not working anymore"
+    regex:
+      - "chronic\\s+pain.*(worse|increasing|flare)"
+      - "pain.*getting\\s+worse"
+  medium:
+    phrases:
+      - "pain is a bit worse than before"
+      - "more pain than usual"
+      - "pain seems to be increasing"
+      - "not getting relief from pain"
+      - "pain coming back stronger"
+  low:
+    partials:
+      - "pain worse"
+      - "chronic pain"
+      - "pain increasing"
+
+negation_handling:
+  patterns:
+    - "pain is better"
+    - "pain improving"
+    - "pain is manageable now"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/worsening_depression_si/flows/clarify.yaml b/decision/taxonomy/worsening_depression_si/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5889331c1654d1933b787da3dbb240e8e2b64c7a
--- /dev/null
+++ b/decision/taxonomy/worsening_depression_si/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: worsening_depression_si
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: worsening_depression_si_clarify
+      goal: "Ask patient to describe their worsening depression si symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - worsening_depression_si_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/worsening_depression_si/flows/escalate_r1.yaml b/decision/taxonomy/worsening_depression_si/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a1e43e4a9c9c50f4f36956de1d66269320acba9b
--- /dev/null
+++ b/decision/taxonomy/worsening_depression_si/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: worsening_depression_si
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/worsening_depression_si/flows/escalate_r2.yaml b/decision/taxonomy/worsening_depression_si/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..240e405c6e1a70c5e378352df47fabe0f7a90c80
--- /dev/null
+++ b/decision/taxonomy/worsening_depression_si/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: worsening_depression_si
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will be connected to discuss their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "connect"
+        - "important"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: urgent
+    response_spec:
+      id: r2_handoff
+      goal: "Warm transfer to nurse with context summary"
+      tone: professional
+      must_include:
+        - "connecting"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/worsening_depression_si/flows/handoff.yaml b/decision/taxonomy/worsening_depression_si/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..16f68679bb76c11c32121c9ea08414bc91543b36
--- /dev/null
+++ b/decision/taxonomy/worsening_depression_si/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: worsening_depression_si
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: worsening_depression_si_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: worsening_depression_si_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/worsening_depression_si/rules.yaml b/decision/taxonomy/worsening_depression_si/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5884530ecb6eab28e4d43cf87fa42c7966bc75da
--- /dev/null
+++ b/decision/taxonomy/worsening_depression_si/rules.yaml
@@ -0,0 +1,27 @@
+domain: worsening_depression_si
+target_risk_class: R2
+
+decision_rules:
+  - id: worsening_depression_si_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r2
+
+  - id: worsening_depression_si_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r2
+
+  - id: worsening_depression_si_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: worsening_depression_si_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/worsening_depression_si/triggers.yaml b/decision/taxonomy/worsening_depression_si/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5859c6a2104ce94ded6c8245cba520f66143c6d6
--- /dev/null
+++ b/decision/taxonomy/worsening_depression_si/triggers.yaml
@@ -0,0 +1,423 @@
+domain: worsening_depression_si
+priority: 50
+
+lexical_signals:
+  high:
+    phrases:
+      # --- ORIGINAL ---
+      - "feeling more depressed and having dark thoughts"
+      - "depression getting worse and thinking about death"
+      - "can't stop thinking about not being here"
+      - "worsening depression with thoughts of death"
+      - "depression worsening and feeling hopeless about life"
+      - "I don't see the point anymore"
+      - "feeling like giving up"
+      - "thoughts about ending things"
+      - "don't want to go on"
+      - "feeling worthless and hopeless"
+      - "crying all the time and can't cope"
+      - "much more depressed since coming home"
+      # --- EXPANDED naturalistic ---
+      - "what's the point of anything"
+      - "I don't care if I wake up tomorrow"
+      - "everything feels pointless"
+      - "I just want this to be over"
+      - "wish I could go to sleep and not wake up"
+      - "nobody would miss me"
+      - "everyone would be better off without me"
+      - "I can't do this anymore"
+      - "I'm done trying"
+      - "nothing matters anymore"
+      - "I feel completely empty inside"
+      - "I've been having really dark thoughts"
+      - "thinking about hurting myself"
+      - "I don't want to be here anymore"
+      - "I have no reason to keep going"
+      - "life isn't worth living"
+      - "I feel dead inside"
+    regex:
+      # --- ORIGINAL ---
+      - "(depression|depressed).*(worse|worsening|dark\\s+thoughts|getting\\s+bad)"
+      - "thinking\\s+about\\s+(death|not\\s+being|ending)"
+      - "(don'?t|no)\\s+(see\\s+the\\s+point|want\\s+to\\s+(go|live|be))"
+      - "(giving|give)\\s+up"
+      - "(hopeless|worthless)\\s+(and|about)"
+      # --- EXPANDED ---
+      - "what'?s\\s+the\\s+point"
+      - "(wish|want).{0,15}(not\\s+wake|go\\s+to\\s+sleep\\s+and\\s+not|disappear|die)"
+      - "(nobody|no\\s+one).{0,15}(miss|care|notice)"
+      - "better\\s+off\\s+without\\s+me"
+      - "(can'?t|cannot)\\s+(do\\s+this|take\\s+(it|this)|go\\s+on|keep\\s+going)"
+      - "done\\s+(with\\s+)?(everything|trying|life|all\\s+(of\\s+)?this)"
+      - "nothing\\s+(matters|is\\s+worth|feels\\s+real)"
+      - "(completely|totally|just)\\s+(empty|numb|hollow)"
+      - "(really|very)\\s+dark\\s+thoughts"
+      - "(hurting|harming)\\s+(myself|me)"
+      - "don'?t\\s+want\\s+to\\s+be\\s+here"
+      - "no\\s+reason\\s+to\\s+(keep|continue|go)"
+      - "(life|living).{0,15}(not\\s+worth|pointless|meaningless)"
+      - "dead\\s+inside"
+      - "(feel|feeling)\\s+like\\s+(a\\s+burden|giving\\s+up|I'?m\\s+a\\s+burden)"
+  medium:
+    phrases:
+      # --- ORIGINAL ---
+      - "feeling more depressed"
+      - "depression is getting worse"
+      - "mood getting darker"
+      - "struggling with dark thoughts"
+      - "not wanting to get out of bed"
+      - "mental health declining"
+      - "feeling really down"
+      - "more depressed than before"
+      - "can't stop crying"
+      - "nothing makes me happy"
+      - "lost interest in everything"
+      - "feeling hopeless"
+      - "really struggling emotionally"
+      - "mood is really low"
+      # --- EXPANDED naturalistic ---
+      - "everything feels heavy"
+      - "I'm just going through the motions"
+      - "I don't care anymore"
+      - "been staying in bed all day"
+      - "not eating much"
+      - "stopped doing things I used to enjoy"
+      - "don't want to talk to anyone"
+      - "isolating myself"
+      - "can't get out of bed"
+      - "haven't showered in days"
+      - "stopped answering the phone"
+      - "I just sit and stare at the wall"
+      - "I don't feel anything"
+      - "haven't left the house in days"
+      - "I stopped caring about everything"
+      - "lost motivation to do anything"
+      - "I can't even make myself eat"
+      - "just want to be alone all the time"
+      - "no energy for anything"
+      - "I feel like a burden"
+      - "everything just feels gray"
+      - "I don't enjoy anything anymore"
+      - "feel like I'm drowning"
+      - "I'm not sleeping at all"
+      - "sleeping all day and still tired"
+      - "my mood is a lot worse since I left the hospital"
+      - "I feel so much worse than before discharge"
+      - "I've been really struggling since I came home"
+      - "getting worse not better"
+      - "I cry for no reason"
+      - "the sadness won't go away"
+      - "constantly on the verge of tears"
+      # --- MINIMIZER coverage ---
+      - "I'm fine, just tired"
+      - "everybody feels down sometimes"
+      - "it's nothing, don't worry about me"
+      - "just a little down I guess"
+      - "probably just the weather"
+      - "not a big deal, just not myself"
+      - "I'm managing, just not great"
+      - "been a bit low but it's probably nothing"
+      - "just haven't felt like doing much"
+      - "I'm okay, just a rough patch"
+      - "don't want to make a big deal out of it"
+      # --- Indirect language patterns (R2 recall) ---
+      - "things have been harder"
+      - "things have been harder lately"
+      - "it's been getting worse"
+      - "getting worse lately"
+      - "not myself lately"
+      - "haven't been myself"
+      - "just not myself"
+      - "harder to get through the day"
+      - "harder to keep going"
+      # --- RED_HERRING / buried mood change ---
+      - "also my mood has been"
+      - "and I guess my mood"
+      - "oh and I've been kind of down"
+      - "by the way I've been feeling"
+      # --- additional functional decline ---
+      - "haven't gotten dressed in days"
+      - "house is a disaster and I don't care"
+      - "stopped taking my medications"
+      # --- Phase 6: R2 recall expansion ---
+      - "feeling worse than before"
+      - "things are getting darker"
+      - "can't see the point"
+      - "nothing helps anymore"
+      - "medications stopped working"
+      - "therapist is worried"
+      # --- Phase 7: Worsening language ---
+      - "getting worse"
+      - "getting so much worse"
+      - "getting harder"
+      - "harder to function"
+      - "more depressed"
+      - "more depressed than usual"
+      - "depression has gotten worse"
+      - "depression has gotten so much worse"
+      - "been really struggling"
+      - "really struggling lately"
+      - "struggling the last few weeks"
+      - "struggling the last couple weeks"
+      - "it's been getting worse"
+      - "things have been getting worse"
+      - "mood has been getting worse"
+      # --- Phase 7: Medication concerns ---
+      - "meds not working"
+      - "meds aren't working"
+      - "medication not working"
+      - "medication isn't working"
+      - "antidepressant not working"
+      - "antidepressant isn't working"
+      - "need to adjust my medication"
+      - "need to adjust my meds"
+      - "side effects are bad"
+      - "side effects are worse"
+      - "missed my medication"
+      - "missed doses"
+      - "might've missed doses"
+      - "haven't been taking my medication"
+      - "stopped taking my meds"
+      # --- Phase 7: Functional decline ---
+      - "can't get out of bed"
+      - "barely get out of bed"
+      - "can barely get out of bed"
+      - "hard to get out of bed"
+      - "stopped doing things"
+      - "stopped doing things I enjoy"
+      - "stopped going out"
+      - "isolating myself"
+      - "been isolating"
+      - "withdrawing from people"
+      - "can't focus at work"
+      - "can't concentrate"
+      - "called out of work"
+      - "called out twice"
+      - "not functioning"
+      - "barely functioning"
+      - "going through the motions"
+      - "just going through the motions"
+      # --- Phase 7: Indirect SI hints ---
+      - "dark thoughts"
+      - "really dark thoughts"
+      - "scary thoughts"
+      - "really scary thoughts"
+      - "having scary thoughts"
+      - "having dark thoughts"
+      - "feeling hopeless"
+      - "completely hopeless"
+      - "don't see the point"
+      - "what's the point"
+      - "I don't see the point anymore"
+      - "there's no point"
+      - "imagining not being here"
+      - "not wanting to be here"
+      - "what if I wasn't around"
+      - "what if I just wasn't around"
+      - "easier if I didn't wake up"
+      - "don't want to wake up"
+      - "thinking about not being here"
+      - "I can't keep doing this"
+      - "can't do this anymore"
+      - "intrusive thoughts"
+      - "intrusive what if thoughts"
+      - "thoughts pop in"
+      - "thoughts keep coming"
+      - "brain is pitching an exit"
+      - "what if I just disappeared"
+      # --- Phase 7: Caregiver concerns ---
+      - "worried about him"
+      - "worried about her"
+      - "really worried about him"
+      - "really worried about her"
+      - "she's not herself"
+      - "he's not himself"
+      - "she hasn't been herself"
+      - "he hasn't been himself"
+      - "concerned about my son"
+      - "concerned about my daughter"
+      - "concerned about my husband"
+      - "concerned about my wife"
+      - "scared for her"
+      - "scared for him"
+      - "something's wrong with him"
+      - "something's wrong with her"
+    regex:
+      # --- EXPANDED ---
+      - "everything\\s+(feels?|is)\\s+(heavy|dark|gray|pointless|hopeless|empty)"
+      - "(just|only)\\s+going\\s+through\\s+the\\s+motions"
+      - "don'?t\\s+care\\s+(about\\s+)?(anything|anymore|any\\s+of)"
+      - "(stayed?|staying|been)\\s+in\\s+bed\\s+(all|the\\s+whole|most\\s+of\\s+the)"
+      - "(not|haven'?t\\s+been|stopped|quit|can'?t)\\s+(eat|sleep|shower|cook|clean)"
+      - "stopped\\s+(doing|going|seeing|talking|caring|answering|leaving)"
+      - "don'?t\\s+want\\s+to\\s+(talk|see\\s+anyone|be\\s+around|leave|go\\s+out)"
+      - "(isolat|withdraw|pulling\\s+away|cutting\\s+(myself|everyone)\\s+off)"
+      - "haven'?t\\s+(left|showered|eaten|slept|gotten\\s+out)"
+      - "(no|zero|lost|don'?t\\s+have)\\s+(energy|motivation|interest|desire|appetite)"
+      - "(feel|feeling|felt)\\s+like\\s+(a\\s+burden|I'?m\\s+drowning|I'?m\\s+sinking)"
+      - "(mood|depression|mental\\s+health).{0,15}(worse|declining|spiraling|tanking)"
+      - "(cry|crying|tears).{0,15}(all\\s+the\\s+time|constantly|for\\s+no\\s+reason|won'?t\\s+stop)"
+      - "(sleep|sleeping)\\s+(all\\s+day|too\\s+much|not\\s+at\\s+all|barely|can'?t)"
+      - "(sadness|emptiness|darkness).{0,15}(won'?t|doesn'?t|never)\\s+(go\\s+away|stop|end|lift)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(just|only).{0,10}(a\\s+)?(little|bit|rough).{0,10}(down|low|off|tired|sad|blue)"
+      - "(fine|okay|managing|alright).{0,10}(just|but).{0,15}(tired|not great|not myself|rough|low|down)"
+      - "(probably|might be).{0,10}(just|nothing|normal|weather|stress|tired|adjustment)"
+      - "(don'?t|didn'?t).{0,10}(want|mean).{0,10}(to|make).{0,10}(big deal|worry|bother|burden)"
+      - "(everybody|everyone|people).{0,15}(feels?|gets?|goes?\\s+through).{0,10}(down|low|this|rough)"
+      # --- Phase 6: R2 recall expansion ---
+      - "(feeling|feel).{0,20}(worse|lower|darker|emptier).{0,20}(than|lately|recently)"
+      - "(can't|cannot).{0,15}(see|find).{0,15}(point|reason|purpose)"
+      - "(nothing|medication|meds|therapy).{0,20}(help|work|helping|working).{0,10}(anymore)?"
+      - "(therapist|counselor|doctor).{0,20}(worried|concerned|wants me to call)"
+      # --- Phase 7: Worsening language regex ---
+      - "(depression|mood|mental\\s+health).{0,20}(getting|gotten|became|has\\s+been).{0,15}(worse|bad|harder)"
+      - "(struggling|really\\s+struggling).{0,20}(lately|recently|the\\s+last|past\\s+few)"
+      - "(it'?s|things).{0,15}(been|getting).{0,15}(worse|harder|bad)"
+      # --- Phase 7: Medication concern regex ---
+      - "(meds?|medication|antidepressant).{0,20}(not|isn'?t|aren'?t|stopped).{0,10}(working|helping)"
+      - "(need\\s+to|should|have\\s+to).{0,15}(adjust|change|switch).{0,15}(med|medication|dose)"
+      - "(missed|skipped|haven'?t\\s+been\\s+taking).{0,15}(dose|medication|meds|pills)"
+      # --- Phase 7: Functional decline regex ---
+      - "(can'?t|barely|hard\\s+to|struggle\\s+to).{0,15}(get\\s+out\\s+of\\s+bed|function|focus|concentrate)"
+      - "(stopped|quit|haven'?t\\s+been).{0,15}(doing\\s+things|going\\s+out|seeing\\s+people|leaving)"
+      - "(called|calling).{0,10}(out|in\\s+sick|off).{0,10}(of\\s+work|from\\s+work|twice|again)"
+      - "(isolating|withdrawing|pulling\\s+away|cutting\\s+off)"
+      # --- Phase 7: Indirect SI regex ---
+      - "(dark|scary|intrusive).{0,10}(thoughts|ideas|feelings)"
+      - "(don'?t|can'?t).{0,15}(see|find).{0,10}(the\\s+)?point"
+      - "(imagining|thinking\\s+about|wondering\\s+about).{0,15}(not\\s+being|disappearing|not\\s+existing)"
+      - "what.{0,10}if.{0,15}(wasn'?t|weren'?t|I\\s+just).{0,10}(around|here)"
+      - "(easier|better).{0,10}if.{0,10}(I\\s+)?didn'?t.{0,10}wake"
+      - "(can'?t|cannot).{0,10}(keep\\s+)?doing\\s+this"
+      - "brain.{0,15}(pitching|suggesting|showing).{0,10}(an\\s+)?exit"
+      # --- Phase 7: Caregiver concern regex ---
+      - "(worried|concerned|scared).{0,15}(about|for).{0,15}(him|her|my\\s+(son|daughter|husband|wife|partner|mom|dad))"
+      - "(she|he).{0,10}(is|has)n'?t.{0,10}(been\\s+)?her(self)?|him(self)?"
+      - "something.{0,10}(is\\s+)?wrong.{0,10}with.{0,10}(him|her|my)"
+    partials:
+      - "going through the motions"
+      - "no motivation"
+      - "no energy"
+      - "isolating"
+      - "withdrawing"
+  low:
+    partials:
+      # --- ORIGINAL ---
+      - "depressed"
+      - "depression worsening"
+      - "dark thoughts"
+      - "hopeless"
+      - "feeling down"
+      - "mood low"
+      - "emotionally struggling"
+      # --- EXPANDED ---
+      - "mood worse"
+      - "anhedonia"
+      - "loss of interest"
+      - "not myself"
+      - "not eating"
+      - "not sleeping"
+      - "staying in bed"
+      - "crying a lot"
+      - "no appetite"
+      - "feel empty"
+      - "feel numb"
+      - "feel worthless"
+      - "apathetic"
+      - "no pleasure"
+      - "sad all the time"
+      - "can't cope"
+      - "mental health"
+      - "suicidal"
+      - "self-harm"
+
+negation_handling:
+  patterns:
+    # --- ORIGINAL ---
+    - "not having dark thoughts"
+    - "depression stable"
+    - "mood improving"
+    # --- EXPANDED ---
+    - "no dark thoughts"
+    - "no thoughts of hurting myself"
+    - "no suicidal thoughts"
+    - "no thoughts of self-harm"
+    - "not suicidal"
+    - "depression is better"
+    - "depression is manageable"
+    - "mood is stable"
+    - "mood is improving"
+    - "mood is better"
+    - "feeling better emotionally"
+    - "mental health is improving"
+    - "started feeling better"
+    - "mood lifted"
+    - "getting out of bed more"
+    - "started eating again"
+    - "sleeping better"
+    - "enjoying things again"
+    - "depression under control"
+    - "no longer having dark thoughts"
+    - "dark thoughts have stopped"
+    - "doing better mentally"
+    - "feeling more like myself"
+    - "more motivated"
+    - "therapy is helping"
+    - "medication is helping"
+    - "antidepressant is working"
+    # --- non-depression context (R1 scenarios) ---
+    - "probably just a routine"
+    - "probably just need a checkup"
+    - "probably nothing serious"
+    - "probably just routine"
+    - "probably just need to"
+    - "probably just normal"
+    - "not eating much since surgery"
+    - "not eating well since the procedure"
+    - "appetite has been poor"
+    - "appetite issue"
+    - "poor oral intake"
+    - "not sleeping because of"
+    - "not sleeping due to"
+    - "not sleeping because I keep"
+    - "scheduling an appointment"
+    - "booking an appointment"
+    - "nothing urgent"
+    - "not an emergency"
+    - "calling about my appointment"
+    - "calling about scheduling"
+    - "calling about my medication"
+    - "calling about my wound"
+    - "calling about my incision"
+    - "calling about my follow-up"
+    - "leaking urine"
+    - "urine leakage"
+    - "incontinence"
+    - "bladder control"
+    - "pelvic floor"
+    - "wearing pads"
+    # --- polite scheduling / politeness disclaimers ---
+    - "don't want to be a bother"
+    - "don't want to be picky"
+    - "don't want to be too early"
+    - "don't want to be too late"
+    - "don't want to be difficult"
+    - "don't want to be annoying"
+    - "don't want to be in the way"
+    - "don't want to be rude"
+    - "don't want to be demanding"
+    - "don't want to take up"
+    - "don't want to overcomplicate"
+    - "don't want to make this more"
+    - "don't want to make a big production"
+    - "don't want to be a burden on the schedule"
+    - "probably nothing"
+    - "probably just a general"
+    - "probably just a check"
+    - "probably just need"
+    - "scheduling"
+    - "schedule an appointment"
+    - "make an appointment"
+    - "need to schedule"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/wound_concern/flows/clarify.yaml b/decision/taxonomy/wound_concern/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8979317561ef7da921772b3a24a5976ec346bd0d
--- /dev/null
+++ b/decision/taxonomy/wound_concern/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: wound_concern
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: wound_concern_clarify
+      goal: "Ask patient to describe their wound concern symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - wound_concern_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/wound_concern/flows/escalate_r1.yaml b/decision/taxonomy/wound_concern/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ed217cfc592e5dfa0d6e04eb691f84c3c7aa7cbf
--- /dev/null
+++ b/decision/taxonomy/wound_concern/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: wound_concern
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/wound_concern/flows/handoff.yaml b/decision/taxonomy/wound_concern/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..50263f6c91d358edccb8b1757d92100c184fb81b
--- /dev/null
+++ b/decision/taxonomy/wound_concern/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: wound_concern
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: wound_concern_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: wound_concern_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/wound_concern/rules.yaml b/decision/taxonomy/wound_concern/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..70929a881cced28b1f83160a8d5ffb02aeaa12e6
--- /dev/null
+++ b/decision/taxonomy/wound_concern/rules.yaml
@@ -0,0 +1,21 @@
+domain: wound_concern
+target_risk_class: R1
+
+decision_rules:
+  - id: wound_concern_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r1
+
+  - id: wound_concern_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r1
+
+  - id: wound_concern_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/decision/taxonomy/wound_concern/triggers.yaml b/decision/taxonomy/wound_concern/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3cf2e90f3aa51545efc1c078be75fe67f13c4ab2
--- /dev/null
+++ b/decision/taxonomy/wound_concern/triggers.yaml
@@ -0,0 +1,34 @@
+domain: wound_concern
+priority: 44
+
+lexical_signals:
+  high:
+    phrases:
+      - "wound looks red around the edges"
+      - "drainage from incision site"
+      - "wound not healing right"
+      - "incision site is sore and red"
+      - "new redness around surgical site"
+      - "wound has changed color"
+    regex:
+      - "wound.*(red|drain|not\\s+healing)"
+      - "incision.*(red|sore|drain)"
+  medium:
+    phrases:
+      - "wound looks different than before"
+      - "some redness near wound"
+      - "slight drainage from wound"
+      - "incision area is tender"
+      - "wound changed appearance"
+  low:
+    partials:
+      - "wound concern"
+      - "incision redness"
+      - "wound appearance"
+
+negation_handling:
+  patterns:
+    - "wound looks good"
+    - "healing well"
+    - "incision is fine"
+  action: downgrade_confidence
diff --git a/decision/taxonomy/wound_infection/flows/clarify.yaml b/decision/taxonomy/wound_infection/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7df4a704b7eb70468990c3bf29abd68a3624b4e2
--- /dev/null
+++ b/decision/taxonomy/wound_infection/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: wound_infection
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: wound_infection_clarify
+      goal: "Ask patient to describe their wound infection symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - wound_infection_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/decision/taxonomy/wound_infection/flows/escalate_r2.yaml b/decision/taxonomy/wound_infection/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ecd004d2c536efff417e677e1d5888a75e43e2fe
--- /dev/null
+++ b/decision/taxonomy/wound_infection/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: wound_infection
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/wound_infection/flows/escalate_r3.yaml b/decision/taxonomy/wound_infection/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a746550768270d8147199b6df0f027d1703deb6f
--- /dev/null
+++ b/decision/taxonomy/wound_infection/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: wound_infection
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r3_escalation_notice
+      goal: "Instruct patient to call 911 immediately and inform them of nurse transfer"
+      tone: calm_direct
+      must_include:
+        - "call 911"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: r3_handoff
+      goal: "Transfer to clinical nurse with context summary"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/wound_infection/flows/handoff.yaml b/decision/taxonomy/wound_infection/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..fcb8fc2a5a433e6d77282ec3af664bc79b553f93
--- /dev/null
+++ b/decision/taxonomy/wound_infection/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: wound_infection
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: wound_infection_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: wound_infection_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/wound_infection/flows/reassure_low_risk.yaml b/decision/taxonomy/wound_infection/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..41826a699846916f20ec81d641f3445e942342d5
--- /dev/null
+++ b/decision/taxonomy/wound_infection/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: wound_infection
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: wound_infection_reassure
+      goal: "Acknowledge the patient's concern about their wound, note that their care team will be informed for routine follow-up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/decision/taxonomy/wound_infection/flows/safety_screen.yaml b/decision/taxonomy/wound_infection/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..987b664caea8772202e7df77f626bcedd8fb0e70
--- /dev/null
+++ b/decision/taxonomy/wound_infection/flows/safety_screen.yaml
@@ -0,0 +1,55 @@
+flow_id: safety_screen
+type: screening
+domain: wound_infection
+
+required_slots:
+  - fever_present
+  - wound_systemic_signs
+  - wound_drainage_change
+  - wound_redness_spreading
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: wound_infection_screen_step1
+      goal: "Gather details about wound appearance and any changes in drainage"
+      tone: calm_urgent
+      must_include:
+        - "wound"
+      must_ask:
+        - "Has the redness around your wound been spreading or getting worse?"
+        - "Have you noticed any change in drainage — more fluid, pus, or a bad smell?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - wound_redness_spreading
+      - wound_drainage_change
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: wound_infection_screen_step2
+      goal: "Screen for systemic infection signs"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "Do you have a fever or feel feverish?"
+        - "Are you feeling chills, body aches, or generally unwell?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - fever_present
+      - wound_systemic_signs
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_r2: escalate_r2
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_r3
diff --git a/decision/taxonomy/wound_infection/rules.yaml b/decision/taxonomy/wound_infection/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..82a2977a76ec30741a92cddca1bce5eb34fc3c9f
--- /dev/null
+++ b/decision/taxonomy/wound_infection/rules.yaml
@@ -0,0 +1,33 @@
+domain: wound_infection
+target_risk_class: R2
+
+decision_rules:
+  - id: wound_infection_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: wound_infection_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: wound_infection_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: wound_infection_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: wound_infection_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/decision/taxonomy/wound_infection/triggers.yaml b/decision/taxonomy/wound_infection/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b3badbb5f87dfe80fb86a5daaa9ff7f0176513bc
--- /dev/null
+++ b/decision/taxonomy/wound_infection/triggers.yaml
@@ -0,0 +1,295 @@
+domain: wound_infection
+priority: 72
+
+lexical_signals:
+  high:
+    phrases:
+      - "wound is red and oozing pus"
+      - "incision looks infected"
+      - "surgical site infection"
+      - "wound dehiscence"
+      - "incision is opening up"
+      - "wound smells bad and is draining"
+      - "leaking yellowish gunk"
+      - "started oozing"
+      - "red streaks from the wound"
+      - "cut is getting infected"
+      - "pus is coming out of my incision"
+      - "green drainage from the wound"
+      - "wound is oozing thick yellow stuff"
+      - "my surgical wound opened up and is draining"
+      - "red streaks going up my arm from the cut"
+      - "wound has a foul smell"
+      - "incision is separating and leaking"
+      - "fever and my wound looks terrible"
+      - "abscess forming near the wound"
+      - "wound site is hot red and swollen"
+      - "cloudy discharge from the incision"
+      - "cellulitis around the wound"
+      - "the stitches area is oozing greenish stuff"
+      - "my wound is weeping and smells rotten"
+    regex:
+      - "(wound|incision|cut|scrape)\\s+(infect|dehisc|opening)"
+      - "surgical\\s+site\\s+infection"
+      - "(wound|cut|incision|scrape).*(ooz|pus|yellow|green|gunk|stink|smell)"
+      - "(red\\s+streak|streaks?\\s+from).*(wound|cut|incision|scrape)"
+      - "(wound|cut|incision|scrape).*(leak|drain).*(yellow|green|pus|gunk)"
+      - "(wound|incision|cut|surgical\\s+site).*(foul|rotten|terrible|awful)\\s+(smell|odor)"
+      - "(pus|abscess|cellulitis).*(wound|incision|cut|surgical)"
+      - "(wound|incision|cut).*(open|separat|split|gap|came\\s+apart)"
+      - "(?<!no )(?<!not )fever.*(wound|incision|cut|surgical)"
+      - "(wound|incision|cut|surgical).*(?<!no )(?<!not )(fever|chills)"
+      - "(thick|cloudy|milky).*(discharge|drainage|fluid).*(wound|incision|cut)"
+      - "(wound|incision|cut).*(thick|cloudy|milky).*(discharge|drainage|fluid)"
+      - "red.{0,15}(streak|line).{0,15}(from|near|around).{0,15}(wound|cut|incision|stitch)"
+      - "(stitch|suture|staple).{0,20}(area|site).{0,20}(ooz|drain|pus|infect|open)"
+  medium:
+    phrases:
+      - "wound is red and swollen"
+      - "incision site looks worse"
+      - "pus coming from wound"
+      - "wound is hot to touch"
+      - "surgical wound not healing"
+      - "drainage from incision"
+      - "cut is acting up"
+      - "scrape is acting weird"
+      - "looks more angry"
+      - "redder and a bit swollen"
+      - "kind of shiny around the edges"
+      - "wound thing"
+      - "hurts more than yesterday"
+      - "it smells bad"
+      - "doing this gross stuff"
+      - "not looking like a normal scab"
+      - "skin looks a bit more red"
+      - "wound is warm when I touch it"
+      - "the area around my stitches is puffy"
+      - "my incision is not looking right"
+      - "wound seems to be getting bigger"
+      - "more swollen than it was yesterday"
+      - "it keeps weeping clear fluid"
+      - "drainage soaking through the bandage"
+      - "the skin around the wound is hard and red"
+      - "my cut is throbbing"
+      - "wound area feels tight and hot"
+      - "it was healing fine but now it looks worse"
+      - "the edges of the wound are puffy and red"
+      - "I changed the bandage and it looked gross"
+      - "there is stuff coming out of my wound"
+      - "wound is tender and warm"
+      - "the scab came off and underneath looks bad"
+      - "fever since the surgery"
+      - "running a temperature and my wound hurts"
+      # --- MINIMIZER coverage ---
+      - "incision site is just a little irritated"
+      - "probably nothing serious, just some redness"
+      - "maybe it looks a bit more red but that's probably just healing"
+      - "there's always been some wetness I think"
+      - "it looked yellowish and kind of thicker"
+      - "probably just part of healing"
+      - "wound isn't that bad, just a little sore"
+      - "just wanted to check, probably fine"
+      - "I caught a weird smell but I'm sure it's nothing"
+      - "bandage gets a bit damp"
+      - "maybe a little warmer than normal around the wound"
+    regex:
+      - "(wound|cut|incision|scrape).{0,30}(acting|look).{0,15}(up|weird|worse|angry|bad|off|gross)"
+      - "(wound|cut|incision|scrape).{0,30}(red|swollen|puffy|warm|hot|sore)"
+      - "(wound|cut|incision|scrape).{0,30}(not\\s+heal|won't\\s+heal|still)"
+      - "(redder|more\\s+red|more\\s+swollen|puffier|angrier).*than\\s+(yesterday|before|last)"
+      - "(cut|wound|scrape|incision).*(few|couple)\\s+days?.*(acting|look|worse|weird)"
+      - "(arm|leg|wrist|hand|knee|finger|shin|foot).*(acting\\s+weird|doing.*gross)"
+      - "shouldn't\\s+still\\s+be\\s+doing\\s+this"
+      - "(nicked|scraped|cut)\\s+(my|him)self.*(annoying|weird|acting)"
+      - "cut.{0,40}(getting|is).{0,20}(weird|worse|gross|infected)"
+      - "gunk\\s+(coming|com[ei]s?)\\s+(out|from)\\s+(of\\s+)?(a\\s+)?(cut|wound|scrape)"
+      - "scrape.*(few|couple)\\s+days.*(annoying|weird|acting|being)"
+      - "something\\s+on\\s+my\\s+skin.*(worry|worri|concern|bother)"
+      - "(wound|incision|cut).*(soak|soaking|bleed).*bandage"
+      - "(wound|incision|cut).*(bigger|spread|expand|widen)"
+      - "bandage.*(soak|soaking|yellow|green|smell)"
+      - "(stitch|suture|staple).{0,30}(puffy|red|swollen|warm|sore)"
+      - "(healing|healed).*(fine|good|well)\\s+(but|then|until)"
+      - "(?<!no )(?<!not )(fever|temperature|chills).*(surgery|procedure|operation)"
+      - "(surgery|procedure|operation).*(?<!no )(?<!not )(fever|temperature|chills)"
+      - "(wound|cut|incision).*(throb|pulse|pound)"
+      - "edges?.*(wound|cut|incision).*(puffy|red|swollen|raised)"
+      - "(wound|cut|incision).*(tight|hard|indurat).*(hot|warm|red)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(wound|cut|incision|scrape).{0,15}(just|only).{0,10}(a\\s+)?(little|bit|slight).{0,10}(irritat|red|sore|warm|tender|swollen)"
+      - "(probably|might be).{0,10}(just|nothing|normal|fine|healing).{0,20}(wound|cut|incision|red|sore)"
+      - "(wound|incision|cut).{0,20}(yellowish|greenish|thicker|damp|wet|moist|smell).{0,15}(kind of|sort of|a bit|a little|I think|I guess)"
+      - "(bandage|dressing).{0,15}(damp|wet|moist|stain|soak|yellow|smell).{0,15}(a bit|a little|kind of|I think)"
+  low:
+    partials:
+      - "wound concern"
+      - "incision red"
+      - "wound drainage"
+      - "oozing"
+      - "pus"
+      - "infected"
+      - "wound swollen"
+      - "cut acting up"
+      - "scrape acting weird"
+      - "red and puffy"
+      - "yellowish drainage"
+      - "smells bad"
+      - "wound warm"
+      - "incision sore"
+      - "surgical site"
+      - "wound weeping"
+      - "bandage soaked"
+      - "wound throbbing"
+      - "wound open"
+      - "discharge from wound"
+      - "wound spreading"
+      - "fever after surgery"
+      - "wound not healing"
+
+negation_handling:
+  patterns:
+    - "wound looks fine"
+    - "incision healing well"
+    - "no infection signs"
+    - "no redness"
+    - "wound is clean"
+    - "scab looks normal"
+    - "no drainage from the wound"
+    - "wound is dry and clean"
+    - "no pus or discharge"
+    - "incision looks good"
+    - "no signs of infection"
+    - "wound is healing nicely"
+    - "redness went away"
+    - "swelling went down around the wound"
+    - "no fever since surgery"
+    - "wound closed up fine"
+    - "no smell from the wound"
+    - "stitches look clean"
+    - "wound is not red"
+    - "bandage is clean when I change it"
+    - "no warmth around the wound"
+    - "incision is not draining"
+    - "wound looks better today"
+    # --- wound_concern (R1) healing/care context ---
+    - "is that normal"
+    - "does it look normal"
+    - "is this okay"
+    - "when to change the dressing"
+    - "how to care for"
+    - "how should it look"
+    - "dressing change"
+    - "just checking"
+    - "wanted to ask about"
+    - "looks like it is healing"
+    - "healing nicely"
+    - "keeping it clean"
+    - "dry and intact"
+    - "glue is intact"
+    - "steri-strips look fine"
+    - "not oozing"
+    - "no pus"
+    - "no drainage"
+    - "not infected"
+    - "looks okay to me"
+    - "incision looks fine"
+    - "just a tiny bit red"
+    - "just a little sore"
+    - "normal healing"
+    # --- wound_concern (R1) care/question context ---
+    - "how often to change"
+    - "when should I change"
+    - "what ointment"
+    - "which ointment"
+    - "what cream"
+    - "wound care instructions"
+    - "care instructions"
+    - "how to clean"
+    - "how to wash"
+    - "can I shower"
+    - "can I get it wet"
+    - "when can I shower"
+    - "bandage question"
+    - "dressing question"
+    - "follow-up appointment"
+    - "follow up appointment"
+    - "when to come back"
+    - "stitches removed"
+    - "when do the stitches come out"
+    - "staples removed"
+    - "looks like it is closing"
+    - "healing up"
+    - "getting smaller"
+    - "scab is forming"
+    # --- normal wound healing context ---
+    - "pink around the stitches"
+    - "skin looks pink"
+    - "just a little pink"
+    - "pinkish"
+    - "clear drainage"
+    - "clear liquid"
+    - "clear fluid"
+    - "small amount of drainage"
+    - "minimal drainage"
+    - "no odor"
+    - "no smell"
+    - "wound check"
+    - "wound looks good"
+    - "how long until healed"
+    - "when are stitches removed"
+    - "when do stitches come out"
+    - "routine wound care"
+    - "normal drainage"
+    - "drainage is normal"
+    - "expected drainage"
+    - "serous drainage"
+    - "serous fluid"
+    # --- Phase 5: R1 false escalation reduction ---
+    # Post-procedure / routine context
+    - "follow-up from surgery"
+    - "post-procedure question"
+    - "routine wound check"
+    - "post-op visit"
+    - "post-op question"
+    - "surgical follow-up"
+    # Healing progress indicators
+    - "looks like it's closing"
+    - "healing up nicely"
+    - "scab forming normally"
+    - "closing up well"
+    - "edges are coming together"
+    # Reassurance-seeking context
+    - "just wanted to make sure"
+    - "is this what healing looks like"
+    - "wanted to double-check"
+    - "making sure it's okay"
+    # Clean wound descriptors
+    - "pink and clean"
+    - "no discharge"
+    - "no odor"
+    - "dry and clean"
+    - "no redness spreading"
+    # Administrative / care instruction context (suppress action candidates)
+    - "wound care instructions"
+    - "when do stitches come out"
+    - "when are stitches removed"
+    - "staple removal"
+    - "suture removal appointment"
+    # --- R1 routine wound care context (suppress) ---
+    - "just checking on wound"
+    - "checking on my wound"
+    - "dressing change question"
+    - "post-op instructions"
+    - "routine wound care"
+    - "wound looks good"
+    - "healing normally"
+    - "looks like it's healing"
+    - "wound is healing"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
diff --git a/decision/tenants/example_academic_mc/tenant.yaml b/decision/tenants/example_academic_mc/tenant.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f96012c819beb489f597420596f01a83c3d59065
--- /dev/null
+++ b/decision/tenants/example_academic_mc/tenant.yaml
@@ -0,0 +1,67 @@
+tenant_id: example_academic_mc
+tenant_name: "University Medical Center"
+
+enabled_wedges:
+  - pde
+  - pre_op
+  - awv
+
+enabled_journeys:
+  - post_discharge_engagement
+  - pre_op_optimization
+  - annual_wellness_visit
+
+custom_escalation_rules:
+  - rule_id: academic_chest_pain_postsurg
+    mode: add
+    domain: chest_pain
+    description: "Post-surgical patients with chest pain always escalate to R3"
+    conditions:
+      slots_present:
+        - chest_pain_onset
+    target_risk_class: R3
+
+institution_context:
+  name: "University Medical Center"
+  type: academic_medical_center
+  nurse_line_number: "1-800-555-0100"
+  ed_name: "UMC Emergency Department"
+  formulary_url: "https://formulary.umc.example.edu"
+  ehr_system: epic
+  timezone: "America/New_York"
+  operating_hours:
+    default:
+      start_hour: 8
+      end_hour: 20
+    saturday:
+      start_hour: 9
+      end_hour: 17
+  custom_protocols:
+    - "UMC-CP-001 Post-Cardiac Surgery Monitoring"
+    - "UMC-CP-002 Transplant Follow-Up"
+
+data_source_config:
+  fhir_base_url: "https://fhir.umc.example.edu/api/FHIR/R4"
+  auth_method: smart_backend
+  client_id: "umc-dce-client-001"
+  key_file: "/etc/dce/keys/umc_private.pem"
+  resource_scopes:
+    - "Patient.read"
+    - "Condition.read"
+    - "MedicationRequest.read"
+    - "Observation.read"
+    - "AllergyIntolerance.read"
+    - "Appointment.read"
+    - "ServiceRequest.read"
+
+branding:
+  institution_name: "University Medical Center"
+  caller_introduction: "Hi, this is Avery calling from University Medical Center."
+  nurse_line_label: "our 24-hour nurse advice line at 1-800-555-0100"
+  emergency_instructions: "go to the UMC Emergency Department or call 911"
+
+compliance_settings:
+  audit_retention_days: 2555
+  phi_logging_enabled: false
+  require_consent_recording: true
+  hipaa_baa_reference: "BAA-UMC-2024-001"
diff --git a/decision/tenants/example_community_hospital/tenant.yaml b/decision/tenants/example_community_hospital/tenant.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6d9f342f7d1c17f4cc32bcd4845bad40bc986165
--- /dev/null
+++ b/decision/tenants/example_community_hospital/tenant.yaml
@@ -0,0 +1,48 @@
+tenant_id: example_community_hospital
+tenant_name: "Riverside Community Hospital"
+
+enabled_wedges:
+  - pde
+
+enabled_journeys:
+  - post_discharge_engagement
+
+custom_escalation_rules: []
+
+institution_context:
+  name: "Riverside Community Hospital"
+  type: community_hospital
+  nurse_line_number: "1-800-555-0200"
+  ed_name: "Riverside Emergency Room"
+  ehr_system: oracle_health
+  timezone: "America/Chicago"
+  operating_hours:
+    default:
+      start_hour: 8
+      end_hour: 18
+
+data_source_config:
+  fhir_base_url: "https://fhir.riverside.example.org/api/FHIR/R4"
+  auth_method: oauth2
+  client_id: "riverside-dce-client"
+  resource_scopes:
+    - "Patient.read"
+    - "Condition.read"
+    - "MedicationRequest.read"
+    - "Observation.read"
+  fallback_source: mock
+
+branding:
+  institution_name: "Riverside Community Hospital"
+  caller_introduction: "Hi, this is Avery calling from Riverside Community Hospital."
+  nurse_line_label: "our nurse line at 1-800-555-0200"
+  emergency_instructions: "go to the Riverside Emergency Room or call 911"
+
+domain_overrides:
+  post_procedure_incontinence:
+    enabled: false
+
+compliance_settings:
+  audit_retention_days: 2555
+  phi_logging_enabled: false
+  require_consent_recording: true
diff --git a/decision/tenants/example_health_system/tenant.yaml b/decision/tenants/example_health_system/tenant.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..15199259105acb601b52ad4b4f79168bac8787e8
--- /dev/null
+++ b/decision/tenants/example_health_system/tenant.yaml
@@ -0,0 +1,84 @@
+tenant_id: example_health_system
+tenant_name: "Mercy Health System"
+
+enabled_wedges:
+  - pde
+  - pre_op
+  - awv
+  - gap_closure
+  - hra
+
+enabled_journeys:
+  - post_discharge_engagement
+  - pre_op_optimization
+  - annual_wellness_visit
+  - gap_closure
+  - health_risk_assessment
+
+custom_escalation_rules:
+  - rule_id: mercy_fall_elderly
+    mode: add
+    domain: fall_high_risk
+    description: "Patients 75+ with any fall report escalate to R2 regardless of injury"
+    conditions:
+      slots_present:
+        - fall_reported
+      slot_values:
+        fall_reported: "yes"
+    target_risk_class: R2
+  - rule_id: mercy_hf_weight_gain
+    mode: add
+    domain: heart_failure_worsening
+    description: "Any weight gain in CHF patients triggers R2 for same-day callback"
+    conditions:
+      slots_present:
+        - weight_change_reported
+    target_risk_class: R2
+
+institution_context:
+  name: "Mercy Health System"
+  type: health_system
+  nurse_line_number: "1-800-555-0300"
+  ed_name: "Mercy Emergency Department"
+  formulary_url: "https://formulary.mercy.example.com"
+  ehr_system: epic
+  timezone: "America/Chicago"
+  operating_hours:
+    default:
+      start_hour: 7
+      end_hour: 21
+    sunday:
+      start_hour: 9
+      end_hour: 17
+  custom_protocols:
+    - "MERCY-001 CHF Readmission Prevention"
+    - "MERCY-002 Opioid Safety Monitoring"
+    - "MERCY-003 Sepsis Screening Protocol"
+
+data_source_config:
+  fhir_base_url: "https://fhir.mercy.example.com/api/FHIR/R4"
+  auth_method: smart_backend
+  client_id: "mercy-dce-client-prod"
+  key_file: "/etc/dce/keys/mercy_private.pem"
+  resource_scopes:
+    - "Patient.read"
+    - "Condition.read"
+    - "MedicationRequest.read"
+    - "Observation.read"
+    - "AllergyIntolerance.read"
+    - "Immunization.read"
+    - "Appointment.read"
+    - "ServiceRequest.read"
+    - "DocumentReference.read"
+
+branding:
+  institution_name: "Mercy Health"
+  caller_introduction: "Hi, this is Avery calling from Mercy Health."
+  nurse_line_label: "our 24-hour Mercy nurse line at 1-800-555-0300"
+  emergency_instructions: "go to the nearest Mercy Emergency Department or call 911"
+
+compliance_settings:
+  audit_retention_days: 2920
+  phi_logging_enabled: false
+  require_consent_recording: true
+  hipaa_baa_reference: "BAA-MERCY-2024-001"
diff --git a/list/context/fhir_mappings.yaml b/list/context/fhir_mappings.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..95b6fa446eb5d6db93754a3721d248023a74ee46
--- /dev/null
+++ b/list/context/fhir_mappings.yaml
@@ -0,0 +1,61 @@
+# FHIR Resource Mappings for Patient Context
+#
+# Maps FHIR resources to PatientContext fields, organized by wedge.
+# Used by PatientContextBuilder to fetch only what's needed (minimum necessary).
+
+# Which FHIR resources to fetch per wedge (minimum necessary principle)
+wedge_resources:
+  post_discharge_engagement:
+    - Patient
+    - Condition
+    - MedicationRequest
+    - Observation  # labs + vitals
+    - AllergyIntolerance
+    - Encounter
+    - DocumentReference  # discharge summary
+    - Appointment
+  pre_op_optimization:
+    - Patient
+    - Condition
+    - MedicationRequest
+    - AllergyIntolerance
+    - ServiceRequest  # scheduled procedures
+    - Appointment
+  annual_wellness_visit:
+    - Patient
+    - Condition
+    - MedicationRequest
+    - Observation
+    - Immunization
+    - AllergyIntolerance
+  gap_closure:
+    - Patient
+    - Condition
+    - Immunization
+    - Observation  # screening results
+  health_risk_assessment:
+    - Patient
+    - Condition
+    - MedicationRequest
+    - Observation  # labs + screenings
+    - AllergyIntolerance
+
+# Default lookback periods per resource type
+lookback_days:
+  Observation_laboratory: 90
+  Observation_vital_signs: 30
+  MedicationRequest: 365
+  Condition: null  # all active, no date filter
+  Encounter: 365
+  Immunization: 730
+  Appointment: 90  # upcoming only
+
+# Freshness thresholds (hours) for staleness detection
+freshness_thresholds:
+  MedicationRequest: 24
+  Condition: 168  # 7 days
+  Observation_laboratory: 48
+  Observation_vital_signs: 24
+  AllergyIntolerance: 720  # 30 days
+  Immunization: 720
+  Appointment: 12
diff --git a/list/global/global_rules.yaml b/list/global/global_rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..fba9211a75732b4ae79f299937048ff7da51af40
--- /dev/null
+++ b/list/global/global_rules.yaml
@@ -0,0 +1,1236 @@
+safety_precedence:
+  # R3 domains ordered by clinical acuity
+  - chest_pain
+  - airway_compromise
+  - shortness_of_breath_rest
+  - copd_acute_respiratory
+  - exertional_dyspnea
+  - severe_bleeding
+  - gi_bleed
+  - stroke_symptoms
+  - acute_limb_deficit
+  - syncope
+  - anaphylaxis
+  - seizure
+  - suicidal_ideation
+  - cssrs_suicide_screen
+  - homicidal_ideation
+  - overdose
+  - thunderclap_headache
+  - pregnancy_emergency
+  - severe_hypoglycemia
+  - dka_hhs
+  - febrile_neutropenia
+  - meningitis_signal
+  - sudden_vision_loss
+  # R2 safety domain — domestic violence / elder abuse
+  - domestic_safety_concern
+
+call_phases:
+  - session_start
+  - active_call
+  - ended
+
+primitive_sequence:
+  - greeting
+  - identity_verify
+  - consent
+
+fallback_flow: primitives/clarify
+
+risk_classes:
+  R0: "No clinical concern identified"
+  R1: "Low-level concern, routine follow-up"
+  R2: "Moderate concern, warm transfer to nurse"
+  R3: "Emergent, instruct patient to call 911 and transfer to nurse"
+
+risk_escalation_rules:
+  - id: chest_pain_with_sob
+    if:
+      domain: chest_pain
+      slots_present:
+        - shortness_of_breath
+      slot_values:
+        shortness_of_breath: "yes"
+    then:
+      risk_class: R3
+
+  - id: chest_pain_with_syncope
+    if:
+      domain: chest_pain
+      slots_present:
+        - syncope_or_dizziness
+      slot_values:
+        syncope_or_dizziness: "yes"
+    then:
+      risk_class: R3
+
+  - id: chest_pain_isolated
+    if:
+      domain: chest_pain
+      slots_present:
+        - chest_pain_severity
+    then:
+      risk_class: R3
+
+  - id: chest_pain_screening_clear
+    if:
+      domain: chest_pain
+      slot_values:
+        shortness_of_breath: "no"
+        syncope_or_dizziness: "no"
+    then:
+      risk_class: R3
+
+  # ── DKA/HHS ──────────────────────────────────────────────────
+  - id: dka_hhs_confirmed_nausea
+    if:
+      domain: dka_hhs
+      slots_present:
+        - nausea_vomiting
+      slot_values:
+        nausea_vomiting: "yes"
+    then:
+      risk_class: R3
+
+  - id: dka_hhs_confirmed_confusion
+    if:
+      domain: dka_hhs
+      slots_present:
+        - confusion_status
+      slot_values:
+        confusion_status: "yes"
+    then:
+      risk_class: R3
+
+  - id: dka_hhs_glucose_critical
+    if:
+      domain: dka_hhs
+      slots_present:
+        - glucose_level_bucket
+      slot_values:
+        glucose_level_bucket: "severe"
+    then:
+      risk_class: R3
+
+  - id: dka_hhs_glucose_high
+    if:
+      domain: dka_hhs
+      slots_present:
+        - glucose_level_bucket
+      slot_values:
+        glucose_level_bucket: "moderate"
+    then:
+      risk_class: R2
+
+  - id: dka_hhs_screening_clear
+    if:
+      domain: dka_hhs
+      slot_values:
+        nausea_vomiting: "no"
+        confusion_status: "no"
+    then:
+      risk_class: R2
+
+  # ── Shortness of Breath at Rest ──────────────────────────────
+  - id: sob_rest_confirmed
+    if:
+      domain: shortness_of_breath_rest
+      slots_present:
+        - sob_at_rest
+      slot_values:
+        sob_at_rest: "yes"
+    then:
+      risk_class: R3
+
+  - id: sob_rest_exertion_only
+    if:
+      domain: shortness_of_breath_rest
+      slot_values:
+        sob_at_rest: "no"
+    then:
+      risk_class: R0
+
+  # ── Wound Infection ──────────────────────────────────────────
+  - id: wound_infection_confirmed_fever
+    if:
+      domain: wound_infection
+      slots_present:
+        - fever_present
+      slot_values:
+        fever_present: "yes"
+    then:
+      risk_class: R3
+
+  - id: wound_infection_confirmed_systemic
+    if:
+      domain: wound_infection
+      slots_present:
+        - wound_systemic_signs
+      slot_values:
+        wound_systemic_signs: "yes"
+    then:
+      risk_class: R3
+
+  - id: wound_infection_screening_clear
+    if:
+      domain: wound_infection
+      slot_values:
+        fever_present: "no"
+        wound_systemic_signs: "no"
+    then:
+      risk_class: R2
+
+  # ── DVT Signal ───────────────────────────────────────────────
+  - id: dvt_signal_confirmed_swelling
+    if:
+      domain: dvt_signal
+      slots_present:
+        - leg_swelling_acute
+      slot_values:
+        leg_swelling_acute: "yes"
+    then:
+      risk_class: R2
+
+  - id: dvt_signal_confirmed_tenderness
+    if:
+      domain: dvt_signal
+      slots_present:
+        - calf_tenderness
+      slot_values:
+        calf_tenderness: "yes"
+    then:
+      risk_class: R2
+
+  - id: dvt_signal_screening_clear
+    if:
+      domain: dvt_signal
+      slot_values:
+        leg_swelling_acute: "no"
+        calf_tenderness: "no"
+    then:
+      risk_class: R0
+
+  # ── Fall High Risk ──────────────────────────────────────────
+  - id: fall_confirmed_loc
+    if:
+      domain: fall_high_risk
+      slot_values:
+        loss_of_consciousness: "yes"
+    then:
+      risk_class: R3
+
+  - id: fall_confirmed_head_strike_anticoag
+    if:
+      domain: fall_high_risk
+      slot_values:
+        head_strike: "yes"
+        on_anticoagulant: "yes"
+    then:
+      risk_class: R3
+
+  - id: fall_confirmed_head_strike
+    if:
+      domain: fall_high_risk
+      slots_present:
+        - head_strike
+      slot_values:
+        head_strike: "yes"
+    then:
+      risk_class: R2
+
+  - id: fall_confirmed_anticoagulant
+    if:
+      domain: fall_high_risk
+      slots_present:
+        - on_anticoagulant
+      slot_values:
+        on_anticoagulant: "yes"
+    then:
+      risk_class: R2
+
+  - id: fall_screening_clear
+    if:
+      domain: fall_high_risk
+      slot_values:
+        head_strike: "no"
+        injury_present: "no"
+    then:
+      risk_class: R0
+
+  # ── Anaphylaxis ─────────────────────────────────────────────
+  - id: anaphylaxis_confirmed_swelling
+    if:
+      domain: anaphylaxis
+      slots_present:
+        - tongue_lip_swelling
+      slot_values:
+        tongue_lip_swelling: "yes"
+    then:
+      risk_class: R3
+
+  - id: anaphylaxis_confirmed_breathing
+    if:
+      domain: anaphylaxis
+      slots_present:
+        - breathing_difficulty_acute
+      slot_values:
+        breathing_difficulty_acute: "yes"
+    then:
+      risk_class: R3
+
+  - id: anaphylaxis_screening_clear
+    if:
+      domain: anaphylaxis
+      slot_values:
+        rash_hives: "no"
+        tongue_lip_swelling: "no"
+        breathing_difficulty_acute: "no"
+    then:
+      risk_class: R0
+
+  # ── Overdose ────────────────────────────────────────────────
+  - id: overdose_confirmed_intentional
+    if:
+      domain: overdose
+      slots_present:
+        - intent
+      slot_values:
+        intent: "intentional"
+    then:
+      risk_class: R3
+
+  - id: overdose_confirmed_altered
+    if:
+      domain: overdose
+      slots_present:
+        - consciousness_level
+      slot_values:
+        consciousness_level: "altered"
+    then:
+      risk_class: R3
+
+  - id: overdose_screening_clear
+    if:
+      domain: overdose
+      slot_values:
+        intent: "accidental"
+        consciousness_level: "alert"
+    then:
+      risk_class: R2
+
+  # ── Stroke Symptoms (BE-FAST) ────────────────────────────────
+  - id: stroke_confirmed_balance
+    if:
+      domain: stroke_symptoms
+      slot_values:
+        balance_deficit: "yes"
+    then:
+      risk_class: R3
+
+  - id: stroke_confirmed_vision
+    if:
+      domain: stroke_symptoms
+      slot_values:
+        vision_change: "yes"
+    then:
+      risk_class: R3
+
+  - id: stroke_confirmed_facial_droop
+    if:
+      domain: stroke_symptoms
+      slots_present:
+        - facial_droop
+      slot_values:
+        facial_droop: "yes"
+    then:
+      risk_class: R3
+
+  - id: stroke_confirmed_arm_weakness
+    if:
+      domain: stroke_symptoms
+      slots_present:
+        - arm_weakness
+      slot_values:
+        arm_weakness: "yes"
+    then:
+      risk_class: R3
+
+  - id: stroke_confirmed_speech
+    if:
+      domain: stroke_symptoms
+      slots_present:
+        - speech_slurring
+      slot_values:
+        speech_slurring: "yes"
+    then:
+      risk_class: R3
+
+  - id: stroke_screening_clear
+    if:
+      domain: stroke_symptoms
+      slot_values:
+        balance_deficit: "no"
+        vision_change: "no"
+        facial_droop: "no"
+        arm_weakness: "no"
+        speech_slurring: "no"
+    then:
+      risk_class: R0
+
+  # ── Exertional Dyspnea ──────────────────────────────────────
+  - id: exertional_dyspnea_new_onset
+    if:
+      domain: exertional_dyspnea
+      slot_values:
+        dyspnea_onset: "new"
+    then:
+      risk_class: R3
+
+  - id: exertional_dyspnea_chronic
+    if:
+      domain: exertional_dyspnea
+      slot_values:
+        dyspnea_onset: "chronic"
+    then:
+      risk_class: R1
+
+  # NOTE: Removed dead exertional_dyspnea_screening_clear rule (duplicate of
+  # exertional_dyspnea_chronic above — both matched dyspnea_onset: chronic,
+  # but first-match semantics meant this R0 rule was unreachable)
+
+  # ── Abnormal BP ────────────────────────────────────────────
+  - id: abnormal_bp_critical_threshold
+    if:
+      domain: abnormal_bp
+      slots_present:
+        - bp_critical
+      slot_values:
+        bp_critical: "yes"
+    then:
+      risk_class: R3
+
+  - id: abnormal_bp_any_report
+    if:
+      domain: abnormal_bp
+      slots_present:
+        - bp_report_confirmed
+      slot_values:
+        bp_report_confirmed: "yes"
+    then:
+      risk_class: R2
+
+  # ── Anticoagulant Hold Failure ─────────────────────────────
+  - id: anticoag_still_taking
+    if:
+      domain: anticoagulant_hold_failure
+      slots_present:
+        - anticoag_still_taking
+      slot_values:
+        anticoag_still_taking: "yes"
+    then:
+      risk_class: R2
+
+  - id: anticoag_hold_compliant
+    if:
+      domain: anticoagulant_hold_failure
+      slot_values:
+        anticoag_still_taking: "no"
+    then:
+      risk_class: R0
+
+  # ── NPO Violation ─────────────────────────────────────────
+  - id: npo_recent_intake
+    if:
+      domain: npo_violation
+      slots_present:
+        - npo_last_intake_time
+      slot_values:
+        npo_intake_recent: "yes"
+    then:
+      risk_class: R2
+
+  - id: npo_compliant
+    if:
+      domain: npo_violation
+      slot_values:
+        npo_intake_recent: "no"
+    then:
+      risk_class: R0
+
+  # ── Acute Illness Pre-Op ──────────────────────────────────
+  - id: preop_illness_fever
+    if:
+      domain: acute_illness_preop
+      slots_present:
+        - illness_fever_present
+      slot_values:
+        illness_fever_present: "yes"
+    then:
+      risk_class: R2
+
+  - id: preop_illness_respiratory
+    if:
+      domain: acute_illness_preop
+      slots_present:
+        - illness_respiratory_symptoms
+      slot_values:
+        illness_respiratory_symptoms: "yes"
+    then:
+      risk_class: R2
+
+  - id: preop_illness_gi
+    if:
+      domain: acute_illness_preop
+      slots_present:
+        - illness_gi_symptoms
+      slot_values:
+        illness_gi_symptoms: "yes"
+    then:
+      risk_class: R2
+
+  - id: preop_illness_clear
+    if:
+      domain: acute_illness_preop
+      slot_values:
+        illness_fever_present: "no"
+        illness_respiratory_symptoms: "no"
+        illness_gi_symptoms: "no"
+    then:
+      risk_class: R0
+
+  # ── Domestic Safety Concern ──────────────────────────────────
+  - id: domestic_safety_immediate_danger
+    if:
+      domain: domestic_safety_concern
+      slots_present:
+        - immediate_danger
+      slot_values:
+        immediate_danger: "yes"
+    then:
+      risk_class: R2
+
+  - id: domestic_safety_not_safe_to_talk
+    if:
+      domain: domestic_safety_concern
+      slots_present:
+        - safe_to_talk
+      slot_values:
+        safe_to_talk: "no"
+    then:
+      risk_class: R2
+
+  - id: domestic_safety_screening_clear
+    if:
+      domain: domestic_safety_concern
+      slot_values:
+        safe_to_talk: "yes"
+        immediate_danger: "no"
+    then:
+      risk_class: R0
+
+  # ── Context-aware risk rules ─────────────────────────────────────────
+  # These rules require BOTH slot conditions AND patient context conditions
+  # to fire. When patient_context is None, context conditions are treated
+  # as non-matching (fail closed).
+
+  - id: sob_chf_decompensation
+    if:
+      domain: shortness_of_breath_rest
+      slots_present:
+        - sob_severity
+      slot_values:
+        sob_severity: "moderate"
+      context:
+        patient_has_condition: ["I50.*"]
+    then:
+      risk_class: R2
+
+  - id: sob_severe_chf_decompensation
+    if:
+      domain: shortness_of_breath_rest
+      slots_present:
+        - sob_severity
+      slot_values:
+        sob_severity: "severe"
+      context:
+        patient_has_condition: ["I50.*"]
+    then:
+      risk_class: R2
+
+  - id: confusion_polypharmacy
+    if:
+      domain: altered_mental_status
+      slots_present:
+        - confusion_reported
+      slot_values:
+        confusion_reported: "yes"
+      context:
+        medication_count_above: 10
+    then:
+      risk_class: R2
+
+  - id: weight_gain_chf_fluid_overload
+    if:
+      domain: weight_gain_sudden
+      slots_present:
+        - weight_change_lbs
+        - weight_gain_significant
+      slot_values:
+        weight_gain_significant: "yes"
+      context:
+        patient_has_condition: ["I50.*"]
+    then:
+      risk_class: R2
+
+  # ══════════════════════════════════════════════════════════════════════════
+  # MH/BH Crisis Line Domains
+  # ══════════════════════════════════════════════════════════════════════════
+
+  # ── C-SSRS Suicide Screen ──────────────────────────────────────────
+  - id: cssrs_q4_intent_yes
+    if:
+      domain: cssrs_suicide_screen
+      slots_present:
+        - cssrs_q4_intent
+      slot_values:
+        cssrs_q4_intent: "yes"
+    then:
+      risk_class: R3
+
+  - id: cssrs_q5_plan_yes
+    if:
+      domain: cssrs_suicide_screen
+      slots_present:
+        - cssrs_q5_plan
+      slot_values:
+        cssrs_q5_plan: "yes"
+    then:
+      risk_class: R3
+
+  - id: cssrs_q6_behavior_yes
+    if:
+      domain: cssrs_suicide_screen
+      slots_present:
+        - cssrs_q6_any_behavior
+      slot_values:
+        cssrs_q6_any_behavior: "yes"
+    then:
+      risk_class: R3
+
+  - id: cssrs_q2_thoughts_yes
+    if:
+      domain: cssrs_suicide_screen
+      slots_present:
+        - cssrs_q2_thoughts_killing
+      slot_values:
+        cssrs_q2_thoughts_killing: "yes"
+    then:
+      risk_class: R2
+
+  - id: cssrs_q3_method_yes
+    if:
+      domain: cssrs_suicide_screen
+      slots_present:
+        - cssrs_q3_method
+      slot_values:
+        cssrs_q3_method: "yes"
+    then:
+      risk_class: R2
+
+  - id: cssrs_screening_clear
+    if:
+      domain: cssrs_suicide_screen
+      slot_values:
+        cssrs_q1_wish_dead: "no"
+        cssrs_q2_thoughts_killing: "no"
+        cssrs_q6_any_behavior: "no"
+    then:
+      risk_class: R1
+
+  # ── Self-Harm Non-Suicidal (NSSI) ─────────────────────────────────
+  - id: nssi_si_crosscheck_positive
+    if:
+      domain: self_harm_nonsuicidal
+      slots_present:
+        - nssi_si_crosscheck
+      slot_values:
+        nssi_si_crosscheck: "yes"
+    then:
+      risk_class: R3
+
+  - id: nssi_medical_severity_severe
+    if:
+      domain: self_harm_nonsuicidal
+      slots_present:
+        - nssi_medical_severity
+      slot_values:
+        nssi_medical_severity: "severe"
+    then:
+      risk_class: R3
+
+  - id: nssi_screening_clear
+    if:
+      domain: self_harm_nonsuicidal
+      slot_values:
+        nssi_si_crosscheck: "no"
+    then:
+      risk_class: R2
+
+  # ── Acute Psychosis ────────────────────────────────────────────────
+  - id: psychosis_command_hallucinations
+    if:
+      domain: acute_psychosis
+      slots_present:
+        - command_hallucinations
+      slot_values:
+        command_hallucinations: "yes"
+    then:
+      risk_class: R3
+
+  - id: psychosis_danger_to_self_others
+    if:
+      domain: acute_psychosis
+      slots_present:
+        - danger_to_self_others
+      slot_values:
+        danger_to_self_others: "yes"
+    then:
+      risk_class: R3
+
+  - id: psychosis_screening_clear
+    if:
+      domain: acute_psychosis
+      slot_values:
+        command_hallucinations: "no"
+        danger_to_self_others: "no"
+    then:
+      risk_class: R2
+
+  # ── Panic Crisis ───────────────────────────────────────────────────
+  - id: panic_cardiac_crosscheck_positive
+    if:
+      domain: panic_crisis
+      slots_present:
+        - somatic_cardiac_crosscheck
+      slot_values:
+        somatic_cardiac_crosscheck: "yes"
+    then:
+      risk_class: R3
+
+  - id: panic_screening_clear
+    if:
+      domain: panic_crisis
+      slot_values:
+        somatic_cardiac_crosscheck: "no"
+    then:
+      risk_class: R2
+
+  # ── Substance Use Crisis ───────────────────────────────────────────
+  - id: substance_seizure_withdrawal
+    if:
+      domain: substance_use_crisis
+      slot_values:
+        seizure_history: "yes"
+        crisis_type: "withdrawal"
+    then:
+      risk_class: R3
+
+  - id: substance_withdrawal_severe
+    if:
+      domain: substance_use_crisis
+      slots_present:
+        - withdrawal_severity
+      slot_values:
+        withdrawal_severity: "severe"
+    then:
+      risk_class: R3
+
+  - id: substance_consciousness_altered
+    if:
+      domain: substance_use_crisis
+      slots_present:
+        - consciousness_status
+      slot_values:
+        consciousness_status: "altered"
+    then:
+      risk_class: R3
+
+  - id: substance_screening_clear
+    if:
+      domain: substance_use_crisis
+      slot_values:
+        seizure_history: "no"
+    then:
+      risk_class: R2
+
+  # ── Psychiatric Medication Crisis ──────────────────────────────────
+  - id: psych_med_benzo_discontinued
+    if:
+      domain: psychiatric_med_crisis
+      slots_present:
+        - med_discontinued
+      slot_values:
+        med_discontinued: "benzodiazepine"
+    then:
+      risk_class: R3
+
+  - id: psych_med_lithium_severe
+    if:
+      domain: psychiatric_med_crisis
+      slot_values:
+        med_discontinued: "lithium"
+        withdrawal_symptoms: "severe"
+    then:
+      risk_class: R3
+
+  - id: psych_med_antipsychotic_psychotic
+    if:
+      domain: psychiatric_med_crisis
+      slot_values:
+        med_discontinued: "antipsychotic"
+        withdrawal_symptoms: "psychotic"
+    then:
+      risk_class: R3
+
+  - id: psych_med_screening_clear
+    if:
+      domain: psychiatric_med_crisis
+      slots_present:
+        - withdrawal_symptoms
+      slot_values:
+        withdrawal_symptoms: "mild"
+    then:
+      risk_class: R2
+
+  # ── CDM Wedge Escalation Rules ──────────────────────────────────────
+  - id: copd_zone_red
+    if:
+      domain: copd_exacerbation
+      slot_values:
+        zone_classification: "red"
+    then:
+      risk_class: R2
+
+  - id: copd_zone_yellow_with_frequent_rescue
+    if:
+      domain: copd_exacerbation
+      slots_present:
+        - zone_classification
+        - rescue_inhaler_use
+      slot_values:
+        zone_classification: "yellow"
+        rescue_inhaler_use: "frequent"
+    then:
+      risk_class: R2
+
+  - id: hf_weight_gain_significant
+    if:
+      domain: hf_volume_overload
+      slots_present:
+        - weight_change
+      slot_values:
+        weight_change: "significant"
+    then:
+      risk_class: R2
+
+  - id: hf_orthopnea_present
+    if:
+      domain: hf_volume_overload
+      slots_present:
+        - orthopnea
+      slot_values:
+        orthopnea: "yes"
+    then:
+      risk_class: R2
+
+  - id: asthma_rescue_frequent_peak_low
+    if:
+      domain: asthma_exacerbation
+      slots_present:
+        - rescue_inhaler_use
+      slot_values:
+        rescue_inhaler_use: "frequent"
+    then:
+      risk_class: R2
+
+  - id: anticoag_bleeding_active
+    if:
+      domain: anticoagulation_monitoring
+      slots_present:
+        - bleeding_signs
+      slot_values:
+        bleeding_signs: "yes"
+    then:
+      risk_class: R2
+
+  - id: anticoag_inr_very_high
+    if:
+      domain: anticoagulation_monitoring
+      slots_present:
+        - inr_result
+      slot_values:
+        inr_result: "very_high"
+    then:
+      risk_class: R2
+
+  # ── Pre-Op Expansion Escalation Rules ───────────────────────────────
+  - id: preop_new_cardiac_symptom
+    if:
+      domain: pre_op_cardiac_clearance
+      slots_present:
+        - new_cardiac_symptom
+      slot_values:
+        new_cardiac_symptom: "yes"
+    then:
+      risk_class: R2
+
+  - id: preop_glucose_very_high
+    if:
+      domain: pre_op_diabetes_optimization
+      slots_present:
+        - glucose_level_concern
+      slot_values:
+        glucose_level_concern: "very_high"
+    then:
+      risk_class: R2
+
+  # ── Clinical Validation Fixes ──────────────────────────────────────────
+
+  # ── Meningitis Signal (CRITICAL: upgraded from R2 to R3) ───────────────
+  # PubMed evidence: Bacterial meningitis 20-30% mortality without treatment.
+  # Triad of fever + headache + neck stiffness warrants R3 escalation.
+  - id: meningitis_confirmed_triad
+    if:
+      domain: meningitis_signal
+      slots_present:
+        - fever_present
+        - neck_stiffness
+      slot_values:
+        fever_present: "yes"
+        neck_stiffness: "yes"
+    then:
+      risk_class: R3
+
+  - id: meningitis_rash_with_fever
+    if:
+      domain: meningitis_signal
+      slots_present:
+        - non_blanching_rash
+        - fever_present
+      slot_values:
+        non_blanching_rash: "yes"
+        fever_present: "yes"
+    then:
+      risk_class: R3
+
+  - id: meningitis_altered_with_fever
+    if:
+      domain: meningitis_signal
+      slots_present:
+        - altered_consciousness
+        - fever_present
+      slot_values:
+        altered_consciousness: "yes"
+        fever_present: "yes"
+    then:
+      risk_class: R3
+
+  # ── Pre-Op Anesthesia: MH Family History (CRITICAL) ───────────────────
+  # PubMed evidence: Malignant hyperthermia mortality 9.5% even with dantrolene.
+  # Family history positive = surgery cannot proceed without MH-safe anesthesia.
+  - id: preop_mh_family_history
+    if:
+      domain: pre_op_anesthesia_concern
+      slots_present:
+        - family_anesthesia_history
+      slot_values:
+        family_anesthesia_history: "yes"
+    then:
+      risk_class: R2
+
+  - id: preop_prior_anesthesia_severe_reaction
+    if:
+      domain: pre_op_anesthesia_concern
+      slots_present:
+        - prior_anesthesia_reaction
+      slot_values:
+        prior_anesthesia_reaction: "severe"
+    then:
+      risk_class: R2
+
+  # ── Progressive Weakness Safety Escalation (CRITICAL) ──────────────────
+  # PubMed evidence: GBS respiratory failure in 30% of cases, cord compression
+  # requires decompression within 24-48h, myasthenic crisis mortality 4-8%.
+  - id: progressive_weakness_ascending
+    if:
+      domain: progressive_weakness
+      slots_present:
+        - ascending_weakness
+      slot_values:
+        ascending_weakness: "yes"
+    then:
+      risk_class: R2
+
+  - id: progressive_weakness_breathing_difficulty
+    if:
+      domain: progressive_weakness
+      slots_present:
+        - breathing_difficulty_new
+      slot_values:
+        breathing_difficulty_new: "yes"
+    then:
+      risk_class: R3
+
+  - id: progressive_weakness_bowel_bladder
+    if:
+      domain: progressive_weakness
+      slots_present:
+        - bowel_bladder_changes
+      slot_values:
+        bowel_bladder_changes: "yes"
+    then:
+      risk_class: R3
+
+  - id: progressive_weakness_swallowing
+    if:
+      domain: progressive_weakness
+      slots_present:
+        - swallowing_difficulty
+      slot_values:
+        swallowing_difficulty: "yes"
+    then:
+      risk_class: R3
+
+  # ── Hypertension Emergency (CRITICAL) ──────────────────────────────────
+  # PubMed evidence: Hypertensive emergency (BP>=180/120 + end-organ damage)
+  # requires immediate ED evaluation. Symptoms: headache, vision changes,
+  # chest pain, SOB, altered mentation, nosebleed.
+  - id: htn_emergency_symptoms
+    if:
+      domain: hypertension_uncontrolled
+      slots_present:
+        - bp_symptoms
+      slot_values:
+        bp_symptoms: "yes"
+    then:
+      risk_class: R2
+
+  - id: htn_emergency_critical_reading
+    if:
+      domain: hypertension_uncontrolled
+      slots_present:
+        - bp_reading_critical
+      slot_values:
+        bp_reading_critical: "yes"
+    then:
+      risk_class: R3
+
+  # ── Psychiatric Med Crisis: NMS and Serotonin Syndrome (CRITICAL) ──────
+  # PubMed evidence: NMS mortality 10-20% even with treatment. Serotonin
+  # syndrome mortality 2-12%. Both require immediate emergency care.
+  - id: psych_med_nms_symptoms
+    if:
+      domain: psychiatric_med_crisis
+      slots_present:
+        - nms_symptoms
+      slot_values:
+        nms_symptoms: "yes"
+    then:
+      risk_class: R3
+
+  - id: psych_med_serotonin_syndrome
+    if:
+      domain: psychiatric_med_crisis
+      slots_present:
+        - serotonin_syndrome_symptoms
+      slot_values:
+        serotonin_syndrome_symptoms: "yes"
+    then:
+      risk_class: R3
+
+  # ── Heart Failure Worsening: Pulmonary Edema (MAJOR) ───────────────────
+  # PubMed evidence: Pink frothy sputum = flash pulmonary edema, requires
+  # immediate ED evaluation. Mortality 12% in-hospital.
+  - id: hf_pink_frothy_sputum
+    if:
+      domain: heart_failure_worsening
+      slots_present:
+        - pink_frothy_sputum
+      slot_values:
+        pink_frothy_sputum: "yes"
+    then:
+      risk_class: R3
+
+  # ── Palpitations with Syncope (MAJOR) ──────────────────────────────────
+  # PubMed evidence: Syncope with palpitations suggests ventricular
+  # tachycardia or other life-threatening arrhythmia. AHA: cardiac syncope
+  # has 1-year mortality 18-33%.
+  - id: palpitations_with_syncope
+    if:
+      domain: palpitations_dizziness
+      slots_present:
+        - syncope_history
+      slot_values:
+        syncope_history: "yes"
+    then:
+      risk_class: R3
+
+  # ── Post-Discharge Fever Very High (MAJOR) ─────────────────────────────
+  # PubMed evidence: Fever >= 103F (39.4C) post-discharge with altered
+  # mentation suggests sepsis. Sepsis mortality increases 7.6% per hour
+  # of delayed treatment.
+  - id: fever_very_high_with_confusion
+    if:
+      domain: post_discharge_fever
+      slots_present:
+        - fever_very_high
+        - confusion_present
+      slot_values:
+        fever_very_high: "yes"
+        confusion_present: "yes"
+    then:
+      risk_class: R3
+
+  - id: fever_very_high
+    if:
+      domain: post_discharge_fever
+      slots_present:
+        - fever_very_high
+      slot_values:
+        fever_very_high: "yes"
+    then:
+      risk_class: R3
+
+  # ── Anticoagulation: Severe Hemorrhage (MAJOR) ─────────────────────────
+  # PubMed evidence: Major hemorrhage on anticoagulation has 9-14% mortality.
+  # Signs: hematemesis, large volume rectal bleeding, hemoptysis, intracranial
+  # hemorrhage symptoms.
+  - id: anticoag_bleeding_severe
+    if:
+      domain: anticoagulation_monitoring
+      slots_present:
+        - bleeding_severity
+      slot_values:
+        bleeding_severity: "severe"
+    then:
+      risk_class: R3
+
+hard_escalate_domains:
+  - suicidal_ideation
+  - homicidal_ideation
+
+turn_outcomes:
+  - proceed
+  - clarify
+  - escalate
+  - handoff
+  - end
+
+# ══════════════════════════════════════════════════════════════════════════════
+# Domain Suppression Rules
+# ══════════════════════════════════════════════════════════════════════════════
+# These rules allow an R1 domain firing at high confidence to suppress
+# an R2/R3 domain, reducing false escalations.
+# The flow engine must be updated separately to consume these rules.
+
+domain_suppression:
+  # ── Wound domains ─────────────────────────────────────────────────────
+  # When R1 wound_concern fires at medium/high confidence, suppress R2 wound_infection
+  # at low/medium confidence (not high - genuine infection signals should still escalate)
+  - suppressor: wound_concern
+    suppressed_domains:
+      - wound_infection
+    condition:
+      suppressor_min_confidence: medium  # medium or high
+      suppressed_max_confidence: medium  # low or medium (not high)
+    reason: "Routine wound concern (R1) contradicts infection (R2) at lower confidence"
+
+  # ── Chest pain domains ────────────────────────────────────────────────
+  # When R1 reproducible_chest_discomfort fires, suppress R3 chest_pain at low/medium
+  - suppressor: reproducible_chest_discomfort
+    suppressed_domains:
+      - chest_pain
+    condition:
+      suppressor_min_confidence: medium
+      suppressed_max_confidence: medium
+    reason: "Reproducible pattern suggests non-ACS chest pain"
+
+  # ── Glucose domains ───────────────────────────────────────────────────
+  # When R1 glucose_out_of_range fires, suppress R3 dka_hhs at low/medium
+  - suppressor: glucose_out_of_range
+    suppressed_domains:
+      - dka_hhs
+      - severe_hypoglycemia
+    condition:
+      suppressor_min_confidence: medium
+      suppressed_max_confidence: medium
+    reason: "Routine glucose management (R1) vs emergency (R3)"
+
+  # ── Medication domains ────────────────────────────────────────────────
+  # When R1 medication fires, suppress R3 overdose at low/medium
+  - suppressor: medication
+    suppressed_domains:
+      - overdose
+    condition:
+      suppressor_min_confidence: medium
+      suppressed_max_confidence: medium
+    reason: "Medication inquiry (R1) vs overdose (R3)"
+
+  # ── Oral intake domains ───────────────────────────────────────────────
+  # When R1 poor_oral_intake fires, suppress R2 persistent_vomiting at low/medium
+  - suppressor: poor_oral_intake
+    suppressed_domains:
+      - persistent_vomiting
+    condition:
+      suppressor_min_confidence: medium
+      suppressed_max_confidence: medium
+    reason: "Appetite concern (R1) vs persistent vomiting (R2)"
+
+  # ── Pain domains ──────────────────────────────────────────────────────
+  # When R1 worsening_chronic_pain fires, suppress R2 uncontrolled_pain at low/medium
+  - suppressor: worsening_chronic_pain
+    suppressed_domains:
+      - uncontrolled_pain
+    condition:
+      suppressor_min_confidence: medium
+      suppressed_max_confidence: medium
+    reason: "Chronic pain management (R1) vs acute uncontrolled pain (R2)"
+
+  # ── MH/BH Crisis Line domain suppression ────────────────────────────
+  # overdose at MEDIUM+ suppresses substance_use_crisis at LOW/MEDIUM
+  - suppressor: overdose
+    suppressed_domains:
+      - substance_use_crisis
+    condition:
+      suppressor_min_confidence: medium
+      suppressed_max_confidence: medium
+    reason: "Active overdose (R3) takes priority over substance use crisis (R2)"
+
+  # C-SSRS screen at MEDIUM+ suppresses worsening_depression_si and NSSI at LOW/MEDIUM
+  - suppressor: cssrs_suicide_screen
+    suppressed_domains:
+      - worsening_depression_si
+      - self_harm_nonsuicidal
+    condition:
+      suppressor_min_confidence: medium
+      suppressed_max_confidence: medium
+    reason: "C-SSRS structured screening supersedes general depression/NSSI assessment"
+
+  # chest_pain at MEDIUM+ suppresses panic_crisis at LOW/MEDIUM
+  - suppressor: chest_pain
+    suppressed_domains:
+      - panic_crisis
+    condition:
+      suppressor_min_confidence: medium
+      suppressed_max_confidence: medium
+    reason: "Chest pain (R3 cardiac) takes priority over panic crisis (R2)"
+
+  # shortness_of_breath_rest at MEDIUM+ suppresses panic_crisis at LOW/MEDIUM
+  - suppressor: shortness_of_breath_rest
+    suppressed_domains:
+      - panic_crisis
+    condition:
+      suppressor_min_confidence: medium
+      suppressed_max_confidence: medium
+    reason: "SOB at rest (R3) takes priority over panic crisis (R2)"
diff --git a/list/journeys/annual_wellness_visit.yaml b/list/journeys/annual_wellness_visit.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..2071cc8e7985ee875966f44dbdc1c18f7b72bca9
--- /dev/null
+++ b/list/journeys/annual_wellness_visit.yaml
@@ -0,0 +1,58 @@
+wedge_type: awv
+display_name: Annual Wellness Visit
+description: >-
+  30-day annual wellness visit preparation journey. Voice calls with SMS
+  reminders. Initial outreach uses the full 12-step agenda. Subsequent calls
+  use abbreviated agendas focused on screening reminders and visit preparation.
+default_duration_days: 30
+steps:
+  - step_id: initial_outreach
+    channel: voice
+    schedule:
+      offset_days: 30
+      window_hours: [9, 17]
+    agenda_sequence:
+      - awv_intro
+      - health_history_update
+      - medication_list_review
+      - family_history_update
+      - functional_status
+      - fall_risk_screening
+      - screening_reminders
+      - immunization_reminders
+      - advance_directives
+      - depression_screening
+      - social_determinants
+      - closing
+    teachback_steps: []
+    max_retries: 3
+    retry_delay_hours: 2
+
+  - step_id: reminder_call
+    channel: voice
+    schedule:
+      offset_days: 7
+      window_hours: [9, 17]
+    agenda_sequence:
+      - awv_intro
+      - screening_reminders
+      - immunization_reminders
+      - social_determinants
+      - closing
+    teachback_steps: []
+    max_retries: 2
+    retry_delay_hours: 4
+
+  - step_id: visit_prep_call
+    channel: voice
+    schedule:
+      offset_days: 2
+      window_hours: [9, 17]
+    agenda_sequence:
+      - awv_intro
+      - medication_list_review
+      - screening_reminders
+      - closing
+    teachback_steps: []
+    max_retries: 2
+    retry_delay_hours: 2
diff --git a/list/journeys/gap_closure.yaml b/list/journeys/gap_closure.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..eb3a4521212d6fde2c089680f3bc5f6fd0790637
--- /dev/null
+++ b/list/journeys/gap_closure.yaml
@@ -0,0 +1,91 @@
+wedge_type: gap_closure
+display_name: Gap Closure
+description: >-
+  30-90 day care gap closure journey. SMS-first channel strategy with voice
+  call escalation for patients who do not respond to SMS reminders. SMS
+  messages are template-driven and do NOT pass through the DCE pipeline.
+  Only voice calls invoke the engine. Voice calls use a 7-step agenda
+  focused on gap identification, barrier assessment, and scheduling assistance.
+default_duration_days: 90
+steps:
+  # Step 1: SMS reminder (template-driven, does not invoke DCE)
+  - step_id: sms_reminder_1
+    channel: sms
+    schedule:
+      offset_days: 1
+      window_hours: [9, 20]
+    agenda_sequence: []
+    teachback_steps: []
+    max_retries: 0
+    retry_delay_hours: 0
+
+  # Step 2: SMS reminder (template-driven, does not invoke DCE)
+  - step_id: sms_reminder_2
+    channel: sms
+    schedule:
+      offset_days: 7
+      window_hours: [9, 20]
+    agenda_sequence: []
+    teachback_steps: []
+    max_retries: 0
+    retry_delay_hours: 0
+
+  # Step 3: SMS reminder (template-driven, does not invoke DCE)
+  - step_id: sms_reminder_3
+    channel: sms
+    schedule:
+      offset_days: 14
+      window_hours: [9, 20]
+    agenda_sequence: []
+    teachback_steps: []
+    max_retries: 0
+    retry_delay_hours: 0
+
+  # Step 4: First voice call — full 7-step gap closure agenda
+  - step_id: initial_outreach_call
+    channel: voice
+    schedule:
+      offset_days: 21
+      window_hours: [9, 17]
+    agenda_sequence:
+      - gap_intro
+      - gap_identification
+      - barrier_assessment
+      - motivational_support
+      - scheduling_assistance
+      - questions
+      - closing
+    teachback_steps: []
+    max_retries: 3
+    retry_delay_hours: 2
+
+  # Step 5: Follow-up voice call — abbreviated agenda
+  - step_id: follow_up_call
+    channel: voice
+    schedule:
+      offset_days: 45
+      window_hours: [9, 17]
+    agenda_sequence:
+      - gap_intro
+      - gap_identification
+      - scheduling_assistance
+      - closing
+    teachback_steps: []
+    max_retries: 2
+    retry_delay_hours: 4
+
+  # Step 6: Final voice call — last attempt
+  - step_id: final_outreach_call
+    channel: voice
+    schedule:
+      offset_days: 75
+      window_hours: [9, 17]
+    agenda_sequence:
+      - gap_intro
+      - gap_identification
+      - barrier_assessment
+      - scheduling_assistance
+      - closing
+    teachback_steps: []
+    max_retries: 2
+    retry_delay_hours: 4
diff --git a/list/journeys/health_risk_assessment.yaml b/list/journeys/health_risk_assessment.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..431c5f0f5741b4552897ec2fd291cb3fbd063942
--- /dev/null
+++ b/list/journeys/health_risk_assessment.yaml
@@ -0,0 +1,45 @@
+wedge_type: hra
+display_name: Health Risk Assessment
+description: >-
+  14-day health risk assessment journey. Voice calls with SMS reminders.
+  Initial call uses the full 10-step agenda covering chronic conditions,
+  functional status, mental health screening, social determinants, and
+  preventive care review. Follow-up call uses abbreviated agenda for
+  incomplete sections.
+default_duration_days: 14
+steps:
+  - step_id: initial_hra_call
+    channel: voice
+    schedule:
+      offset_days: 1
+      window_hours: [9, 17]
+    agenda_sequence:
+      - hra_intro
+      - chronic_condition_inventory
+      - functional_status_assessment
+      - mental_health_screen
+      - social_determinants_screen
+      - medication_burden_review
+      - preventive_care_review
+      - care_plan_summary
+      - closing
+      - wrap_up
+    teachback_steps: []
+    max_retries: 3
+    retry_delay_hours: 2
+
+  - step_id: followup_hra_call
+    channel: voice
+    schedule:
+      offset_days: 7
+      window_hours: [9, 17]
+    agenda_sequence:
+      - hra_intro
+      - mental_health_screen
+      - social_determinants_screen
+      - preventive_care_review
+      - care_plan_summary
+      - closing
+    teachback_steps: []
+    max_retries: 2
+    retry_delay_hours: 4
diff --git a/list/journeys/post_discharge_engagement.yaml b/list/journeys/post_discharge_engagement.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0be50561587b0488ce1eb4981a0f308e7cf48dae
--- /dev/null
+++ b/list/journeys/post_discharge_engagement.yaml
@@ -0,0 +1,120 @@
+wedge_type: pde
+display_name: Post-Discharge Engagement
+description: >-
+  3-30 day post-discharge follow-up journey. Voice calls with SMS reminders.
+  Day 1 uses the full 14-step agenda. Subsequent calls use abbreviated agendas
+  focused on evolving patient needs.
+default_duration_days: 30
+steps:
+  - step_id: day1_call
+    channel: voice
+    schedule:
+      offset_days: 1
+      window_hours: [9, 17]
+    agenda_sequence:
+      - intro_permission
+      - discharge_context
+      - teachback_diagnosis
+      - teachback_warning_signs
+      - general_status
+      - symptom_review
+      - meds_reconciliation
+      - appointments_check
+      - pending_tests
+      - home_services
+      - problem_solving
+      - emergency_plan
+      - closing
+      - wrap_up
+    teachback_steps:
+      - teachback_diagnosis
+      - teachback_warning_signs
+    max_retries: 3
+    retry_delay_hours: 2
+    conditional_probes:
+      - probe_id: chf_symptom_review
+        when:
+          patient_has_condition: ["I50.*"]
+        must_ask:
+          - "Have you been weighing yourself daily as instructed?"
+          - "Have you noticed any new or worsening swelling in your legs or ankles?"
+          - "Have you had any trouble breathing when lying flat?"
+        slots_to_extract: ["daily_weight_check", "edema_worsening", "orthopnea"]
+        reason: "CHF-specific symptom monitoring per AHA guidelines"
+      - probe_id: copd_symptom_review
+        when:
+          patient_has_condition: ["J44.*", "J43.*"]
+        must_ask:
+          - "Have you noticed any change in your sputum color or amount?"
+          - "Are you using your rescue inhaler more than usual?"
+        slots_to_extract: ["sputum_change", "rescue_inhaler_frequency"]
+        reason: "COPD exacerbation early detection"
+      - probe_id: diabetes_symptom_review
+        when:
+          patient_has_condition: ["E11.*", "E10.*"]
+        must_ask:
+          - "Have you been checking your blood sugar regularly?"
+          - "Have you had any episodes of very high or very low blood sugar?"
+        slots_to_extract: ["glucose_monitoring", "glucose_extremes"]
+        reason: "Post-discharge glucose management"
+    pre_populated_slots:
+      - slot: discharge_med_count
+        source_field: discharge_info.discharge_medications
+        reason: "Pre-populate from discharge medication list"
+
+  - step_id: day3_call
+    channel: voice
+    schedule:
+      offset_days: 3
+      window_hours: [9, 17]
+    agenda_sequence:
+      - intro_permission
+      - general_status
+      - symptom_review
+      - meds_reconciliation
+      - closing
+    teachback_steps: []
+    max_retries: 2
+    retry_delay_hours: 4
+
+  - step_id: day7_call
+    channel: voice
+    schedule:
+      offset_days: 7
+      window_hours: [9, 17]
+    agenda_sequence:
+      - intro_permission
+      - appointments_check
+      - problem_solving
+      - closing
+    teachback_steps: []
+    max_retries: 2
+    retry_delay_hours: 4
+
+  - step_id: day14_call
+    channel: voice
+    schedule:
+      offset_days: 14
+      window_hours: [9, 17]
+    agenda_sequence:
+      - intro_permission
+      - general_status
+      - symptom_review
+      - closing
+    teachback_steps: []
+    max_retries: 2
+    retry_delay_hours: 4
+
+  - step_id: day30_call
+    channel: voice
+    schedule:
+      offset_days: 30
+      window_hours: [9, 17]
+    agenda_sequence:
+      - intro_permission
+      - general_status
+      - emergency_plan
+      - closing
+    teachback_steps: []
+    max_retries: 2
+    retry_delay_hours: 4
diff --git a/list/journeys/pre_op_optimization.yaml b/list/journeys/pre_op_optimization.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4f9f051739e6ad021ee4c24af7ad0e5b7ffce76a
--- /dev/null
+++ b/list/journeys/pre_op_optimization.yaml
@@ -0,0 +1,83 @@
+wedge_type: pre_op
+display_name: Pre-Op Optimization
+description: >-
+  7-90 day pre-surgery optimization journey. Voice calls with SMS reminders.
+  Initial call uses the full 10-step agenda. Subsequent calls use abbreviated
+  agendas focused on compliance verification and anxiety management.
+default_duration_days: 90
+steps:
+  - step_id: initial_assessment
+    channel: voice
+    schedule:
+      offset_days: 7
+      window_hours: [9, 17]
+    agenda_sequence:
+      - preop_intro
+      - health_history_update
+      - medication_review
+      - allergy_verification
+      - npo_status
+      - anxiety_screening
+      - procedure_prep
+      - logistics
+      - questions
+      - closing
+    teachback_steps:
+      - npo_status
+    max_retries: 3
+    retry_delay_hours: 2
+    conditional_probes:
+      - probe_id: anticoagulant_hold_check
+        when:
+          patient_on_medication_class: ["anticoagulant", "DOAC"]
+        must_ask:
+          - "Have you stopped taking your blood thinner as instructed?"
+          - "When did you take your last dose?"
+        slots_to_extract: ["anticoag_stopped", "last_anticoag_dose"]
+        reason: "Anticoagulant hold verification per ERAS guidelines"
+      - probe_id: glp1_hold_check
+        when:
+          patient_on_medication_class: ["GLP-1_agonist"]
+        must_ask:
+          - "Have you stopped taking your GLP-1 medication as instructed?"
+        slots_to_extract: ["glp1_stopped"]
+        reason: "GLP-1 agonist hold per updated ERAS guidelines"
+      - probe_id: insulin_management
+        when:
+          patient_on_medication_class: ["insulin"]
+        must_ask:
+          - "Have you adjusted your insulin dose as your surgeon instructed?"
+        slots_to_extract: ["insulin_adjusted"]
+        reason: "Perioperative insulin management"
+
+  - step_id: compliance_check
+    channel: voice
+    schedule:
+      offset_days: 3
+      window_hours: [9, 17]
+    agenda_sequence:
+      - preop_intro
+      - medication_review
+      - npo_status
+      - anxiety_screening
+      - closing
+    teachback_steps:
+      - npo_status
+    max_retries: 2
+    retry_delay_hours: 4
+
+  - step_id: day_before_call
+    channel: voice
+    schedule:
+      offset_days: 1
+      window_hours: [9, 17]
+    agenda_sequence:
+      - preop_intro
+      - npo_status
+      - logistics
+      - anxiety_screening
+      - closing
+    teachback_steps:
+      - npo_status
+    max_retries: 2
+    retry_delay_hours: 2
diff --git a/list/orchestrator/conflict_resolution.yaml b/list/orchestrator/conflict_resolution.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..158df221b12c785ddb0fdd1bc3a91e9aec75cc57
--- /dev/null
+++ b/list/orchestrator/conflict_resolution.yaml
@@ -0,0 +1,79 @@
+# Cross-wedge conflict resolution rules.
+# When two wedges compete for the same contact slot, these rules decide
+# which one proceeds and what happens to the other.
+
+conflict_rules:
+  # PDE and Pre-Op on same day: PDE wins (higher priority_rank), Pre-Op defers
+  - rule_id: pde_preop_same_day
+    wedge_a: pde
+    wedge_b: pre_op
+    condition: same_day
+    winner: higher_priority
+    loser_action: defer_24h
+
+  # Tier 1 vs Tier 2 on same day: Tier 1 always wins
+  - rule_id: tier1_beats_tier2
+    wedge_a: pde
+    wedge_b: awv
+    condition: same_day
+    winner: higher_priority
+    loser_action: defer_24h
+
+  - rule_id: tier1_beats_gap
+    wedge_a: pde
+    wedge_b: gap_closure
+    condition: same_day
+    winner: higher_priority
+    loser_action: defer_24h
+
+  - rule_id: tier1_beats_hra
+    wedge_a: pde
+    wedge_b: hra
+    condition: same_day
+    winner: higher_priority
+    loser_action: defer_24h
+
+  - rule_id: preop_beats_awv
+    wedge_a: pre_op
+    wedge_b: awv
+    condition: same_day
+    winner: higher_priority
+    loser_action: defer_24h
+
+  - rule_id: preop_beats_gap
+    wedge_a: pre_op
+    wedge_b: gap_closure
+    condition: same_day
+    winner: higher_priority
+    loser_action: defer_24h
+
+  - rule_id: preop_beats_hra
+    wedge_a: pre_op
+    wedge_b: hra
+    condition: same_day
+    winner: higher_priority
+    loser_action: defer_24h
+
+  # Within Tier 2: AWV > Gap Closure > HRA (by priority_rank)
+  - rule_id: awv_beats_gap
+    wedge_a: awv
+    wedge_b: gap_closure
+    condition: same_day
+    winner: higher_priority
+    loser_action: defer_24h
+
+  - rule_id: awv_beats_hra
+    wedge_a: awv
+    wedge_b: hra
+    condition: same_day
+    winner: higher_priority
+    loser_action: defer_24h
+
+  - rule_id: gap_beats_hra
+    wedge_a: gap_closure
+    wedge_b: hra
+    condition: same_day
+    winner: higher_priority
+    loser_action: defer_24h
+
+default_loser_action: defer_24h
diff --git a/list/orchestrator/contact_caps.yaml b/list/orchestrator/contact_caps.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..301a065a9d2fa3d47214a98b0e5702529a1e6773
--- /dev/null
+++ b/list/orchestrator/contact_caps.yaml
@@ -0,0 +1,16 @@
+global_max_per_day: 2
+global_max_per_week: 7
+channel_caps:
+  - channel: voice
+    max_per_day: 1
+    max_per_week: 5
+  - channel: sms
+    max_per_day: 2
+    max_per_week: 10
+  - channel: email
+    max_per_day: 1
+    max_per_week: 3
+quiet_hours:
+  start: "21:00"
+  end: "09:00"
+emergency_override: true
diff --git a/list/orchestrator/enrollment_rules.yaml b/list/orchestrator/enrollment_rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..272599c98f41c1cf6e521b3a567165468f7c6b01
--- /dev/null
+++ b/list/orchestrator/enrollment_rules.yaml
@@ -0,0 +1,53 @@
+# Enrollment rules for journey lifecycle management.
+# Controls eligibility, deduplication, and cooldown periods.
+
+dedup_key_fields:
+  - patient_id
+  - wedge_type
+  - trigger_event_id
+
+enrollment_criteria:
+  - wedge_type: pde
+    required_events:
+      - adt_discharge
+    eligible_statuses:
+      - discharged
+    cooldown_days: 30
+    max_concurrent_journeys: 1
+
+  - wedge_type: pre_op
+    required_events:
+      - surgery_scheduled
+    eligible_statuses:
+      - scheduled
+    cooldown_days: 7
+    max_concurrent_journeys: 1
+
+  - wedge_type: awv
+    required_events:
+      - awv_eligible
+    eligible_statuses:
+      - eligible
+    cooldown_days: 365
+    max_concurrent_journeys: 1
+
+  - wedge_type: gap_closure
+    required_events:
+      - gap_identified
+    eligible_statuses:
+      - open
+    cooldown_days: 90
+    max_concurrent_journeys: 3
+
+  - wedge_type: hra
+    required_events:
+      - hra_eligible
+    eligible_statuses:
+      - eligible
+    cooldown_days: 365
+    max_concurrent_journeys: 1
+
+global_enrollment_settings:
+  max_active_journeys_per_patient: 3
+  require_consent: true
+  allow_re_enrollment: true
diff --git a/list/orchestrator/wedge_priority.yaml b/list/orchestrator/wedge_priority.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..97d047c81ac6000ff1ae1b592db6d02a6b5c4b26
--- /dev/null
+++ b/list/orchestrator/wedge_priority.yaml
@@ -0,0 +1,16 @@
+priorities:
+  - wedge_type: pde
+    safety_tier: 1
+    priority_rank: 100
+  - wedge_type: pre_op
+    safety_tier: 1
+    priority_rank: 90
+  - wedge_type: awv
+    safety_tier: 2
+    priority_rank: 50
+  - wedge_type: gap_closure
+    safety_tier: 2
+    priority_rank: 40
+  - wedge_type: hra
+    safety_tier: 2
+    priority_rank: 30
diff --git a/list/orchestrator/wedge_suppression.yaml b/list/orchestrator/wedge_suppression.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5af11f58704fe23630ddf5dd6957015107dc6244
--- /dev/null
+++ b/list/orchestrator/wedge_suppression.yaml
@@ -0,0 +1,78 @@
+# Temporal suppression rules for cross-wedge contact orchestration.
+# After certain events, suppress outbound contacts for specified wedges.
+# Escalation lock suppression blocks ALL wedges for ALL channels.
+
+suppression_rules:
+  # After any PDE voice call, suppress routine wedges for 24 hours
+  - rule_id: pde_call_suppresses_routine
+    trigger_wedge: pde
+    trigger_event: call_completed
+    suppress_wedges:
+      - awv
+      - gap_closure
+      - hra
+    suppress_channels:
+      - voice
+      - sms
+      - email
+    duration_hours: 24
+
+  # After any Pre-Op voice call, suppress routine wedges for 24 hours
+  - rule_id: preop_call_suppresses_routine
+    trigger_wedge: pre_op
+    trigger_event: call_completed
+    suppress_wedges:
+      - awv
+      - gap_closure
+      - hra
+    suppress_channels:
+      - voice
+      - sms
+      - email
+    duration_hours: 24
+
+  # After R3 escalation lock, suppress ALL wedges (all channels)
+  - rule_id: r3_lock_suppresses_all
+    trigger_wedge: any
+    trigger_event: escalation_lock_r3
+    suppress_wedges:
+      - pde
+      - pre_op
+      - awv
+      - gap_closure
+      - hra
+    suppress_channels:
+      - voice
+      - sms
+      - email
+    duration_hours: 24
+
+  # After R2 escalation lock, suppress ALL wedges (all channels)
+  - rule_id: r2_lock_suppresses_all
+    trigger_wedge: any
+    trigger_event: escalation_lock_r2
+    suppress_wedges:
+      - pde
+      - pre_op
+      - awv
+      - gap_closure
+      - hra
+    suppress_channels:
+      - voice
+      - sms
+      - email
+    duration_hours: 72
+
+  # After any voice call, suppress voice for same patient for 4 hours
+  - rule_id: voice_cooldown
+    trigger_wedge: any
+    trigger_event: call_completed
+    suppress_wedges:
+      - pde
+      - pre_op
+      - awv
+      - gap_closure
+      - hra
+    suppress_channels:
+      - voice
+    duration_hours: 4
diff --git a/list/primitives/clarify.yaml b/list/primitives/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e262cc20a807c6065b6df8411d10a2f2e0641074
--- /dev/null
+++ b/list/primitives/clarify.yaml
@@ -0,0 +1,23 @@
+flow_id: clarify
+type: primitive
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: global_clarify
+      goal: "Ask the patient to repeat or clarify what they said"
+      tone: gentle_professional
+      must_include:
+        - "understand"
+      must_ask:
+        - "could you say that again"
+      must_not:
+        - "diagnos"
+      max_questions: 1
+    collects:
+      - clarification_text
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/primitives/consent.yaml b/list/primitives/consent.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c2fb2e865a355db5628652f343d59270ca6a9ae5
--- /dev/null
+++ b/list/primitives/consent.yaml
@@ -0,0 +1,29 @@
+flow_id: consent
+type: primitive
+
+required_slots:
+  - consent_given
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: consent_request
+      goal: "Obtain verbal consent to proceed with post-discharge check-in"
+      tone: warm_professional
+      must_include:
+        - "consent"
+        - "proceed"
+      must_ask:
+        - "okay to continue"
+      must_not:
+        - "required"
+        - "must"
+        - "have to"
+      max_questions: 1
+    collects:
+      - consent_given
+
+exit:
+  on_complete: recovery_checkin
+  on_refused: end_no_consent
diff --git a/list/primitives/end_identity_failed.yaml b/list/primitives/end_identity_failed.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1e10c65986d65c51293f6826a09aa2c772c3eb79
--- /dev/null
+++ b/list/primitives/end_identity_failed.yaml
@@ -0,0 +1,27 @@
+flow_id: end_identity_failed
+type: primitive
+
+# Terminal state when identity verification fails after max attempts.
+# Per HIPAA telephone rules: do not disclose which identifier was wrong.
+# Apologize, cite privacy standards, and end the clinical portion.
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: end_identity_failed
+      goal: "End the call due to identity verification failure, citing privacy standards"
+      tone: warm_professional
+      must_include:
+        - "privacy"
+        - "verify"
+      must_ask: []
+      must_not:
+        - "wrong"
+        - "incorrect"
+        - "mismatch"
+        - "diagnos"
+        - "condition"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/primitives/end_no_consent.yaml b/list/primitives/end_no_consent.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0f2fb6d3b8fe52cb58d7c7a92b6bfa9a2d141a64
--- /dev/null
+++ b/list/primitives/end_no_consent.yaml
@@ -0,0 +1,22 @@
+flow_id: end_no_consent
+type: primitive
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: end_no_consent
+      goal: "Acknowledge the patient's decision to decline and end the call respectfully"
+      tone: warm_respectful
+      must_include:
+        - "understand"
+        - "respect"
+      must_ask: []
+      must_not:
+        - "must"
+        - "have to"
+        - "required"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/primitives/greeting.yaml b/list/primitives/greeting.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..99d708ee7adf75d3984aaa5f3d6ddd82a9a4fd6b
--- /dev/null
+++ b/list/primitives/greeting.yaml
@@ -0,0 +1,22 @@
+flow_id: greeting
+type: primitive
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: greeting_intro
+      goal: "Greet the patient warmly and introduce yourself as Avery, a post-discharge care assistant"
+      tone: warm_professional
+      must_include:
+        - "Avery"
+        - "checking in"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "doctor"
+        - "nurse"
+      max_questions: 0
+
+exit:
+  on_complete: identity_verify
diff --git a/list/primitives/handoff.yaml b/list/primitives/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f0dce7f032e509092f912663e1f4ad0f74cf3ea6
--- /dev/null
+++ b/list/primitives/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: primitive
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: global_handoff_notice
+      goal: "Let the patient know they will be connected with a person who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "someone"
+      must_ask: []
+      must_not:
+        - "goodbye"
+        - "diagnos"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: global_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/primitives/identity_verify.yaml b/list/primitives/identity_verify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ed104ce855ff8f14377fb0871af851f948777fec
--- /dev/null
+++ b/list/primitives/identity_verify.yaml
@@ -0,0 +1,36 @@
+flow_id: identity_verify
+type: primitive
+
+# Joint Commission NPSG.01.01.01: Use at least two patient identifiers.
+# HIPAA telephone rules: full name + at least two identifying pieces of info.
+# For outbound calls, the system already knows the patient's identity from
+# the scheduling system.  We confirm name + DOB = two-factor verification.
+required_slots:
+  - patient_name_confirm
+  - patient_dob
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: identity_name_dob_request
+      goal: "Verify patient identity by asking for their full name and date of birth"
+      tone: warm_professional
+      must_include:
+        - "verify"
+        - "name"
+        - "date of birth"
+      must_ask:
+        - "full name"
+        - "date of birth"
+      must_not:
+        - "diagnos"
+        - "social security"
+        - "medical record"
+      max_questions: 2
+    collects:
+      - patient_name_confirm
+      - patient_dob
+
+exit:
+  on_complete: consent
diff --git a/list/primitives/recovery_checkin.yaml b/list/primitives/recovery_checkin.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8ecedf107f12dc9c8b8aeb1d2ba71c4a852fd377
--- /dev/null
+++ b/list/primitives/recovery_checkin.yaml
@@ -0,0 +1,64 @@
+flow_id: recovery_checkin
+type: primitive
+
+required_slots:
+  - pain_level
+  - medication_adherence
+  - activity_level
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: recovery_pain_check
+      goal: "Ask about current pain level and general recovery"
+      tone: warm_empathetic
+      must_include:
+        - "recovery"
+        - "pain"
+      must_ask:
+        - "How are you feeling"
+        - "pain"
+      must_not:
+        - "diagnos"
+        - "should be"
+      max_questions: 2
+    collects:
+      - pain_level
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: recovery_medication_check
+      goal: "Check medication adherence and any issues"
+      tone: warm_professional
+      must_include:
+        - "medication"
+      must_ask:
+        - "taking your medications"
+      must_not:
+        - "must"
+        - "have to"
+      max_questions: 2
+    collects:
+      - medication_adherence
+
+  - step: 3
+    type: ask
+    response_spec:
+      id: recovery_activity_check
+      goal: "Check activity level and mobility"
+      tone: warm_encouraging
+      must_include:
+        - "activity"
+      must_ask:
+        - "getting around"
+      must_not:
+        - "should be doing more"
+      max_questions: 1
+    collects:
+      - activity_level
+
+exit:
+  on_complete: wrap_up
+  on_concern: evaluate_concern
diff --git a/list/primitives/stt_repair.yaml b/list/primitives/stt_repair.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..262f821558d47ddd2ace05368246fb1eea851e84
--- /dev/null
+++ b/list/primitives/stt_repair.yaml
@@ -0,0 +1,22 @@
+flow_id: stt_repair
+type: primitive
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: stt_repair_request
+      goal: "Ask the patient to repeat what they said due to audio issues"
+      tone: gentle_professional
+      must_include:
+        - "hear"
+      must_ask:
+        - "say that again"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/primitives/wrap_up.yaml b/list/primitives/wrap_up.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3093f72f257b7c607a86b34805ee2b8748cbe0b4
--- /dev/null
+++ b/list/primitives/wrap_up.yaml
@@ -0,0 +1,21 @@
+flow_id: wrap_up
+type: primitive
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: wrap_up_closing
+      goal: "Thank the patient, summarize any follow-ups, and close the call"
+      tone: warm_professional
+      must_include:
+        - "thank you"
+        - "care team"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/abnormal_bp/flows/clarify.yaml b/list/taxonomy/abnormal_bp/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..69106a878aafc344812cd4155e1d0bfc3c3f6b59
--- /dev/null
+++ b/list/taxonomy/abnormal_bp/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: abnormal_bp
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: abnormal_bp_clarify
+      goal: "Ask patient to describe their abnormal bp symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - abnormal_bp_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/abnormal_bp/flows/escalate_r1.yaml b/list/taxonomy/abnormal_bp/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e62de9f3d253a0d241dc4facd395aa51e002c55a
--- /dev/null
+++ b/list/taxonomy/abnormal_bp/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: abnormal_bp
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/abnormal_bp/flows/escalate_r2.yaml b/list/taxonomy/abnormal_bp/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e7997739c5b314e46198fcc8b91f88f97a8e447b
--- /dev/null
+++ b/list/taxonomy/abnormal_bp/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: abnormal_bp
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will be connected to discuss their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "connect"
+        - "important"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: urgent
+    response_spec:
+      id: r2_handoff
+      goal: "Warm transfer to nurse with context summary"
+      tone: professional
+      must_include:
+        - "connecting"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/abnormal_bp/flows/escalate_r3.yaml b/list/taxonomy/abnormal_bp/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a53dd475f5f0fd04f1d80adcb2677f0537356211
--- /dev/null
+++ b/list/taxonomy/abnormal_bp/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: abnormal_bp
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Instruct patient to call 911 immediately and inform them of nurse transfer
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/abnormal_bp/flows/handoff.yaml b/list/taxonomy/abnormal_bp/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4110f824f8d3dcc3f09cc3fe31948598e1b51a6b
--- /dev/null
+++ b/list/taxonomy/abnormal_bp/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: abnormal_bp
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: abnormal_bp_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: abnormal_bp_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/abnormal_bp/flows/safety_screen.yaml b/list/taxonomy/abnormal_bp/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..59234ca0ea43b07de797abf6d8cd3f0ff6122d3b
--- /dev/null
+++ b/list/taxonomy/abnormal_bp/flows/safety_screen.yaml
@@ -0,0 +1,37 @@
+flow_id: safety_screen
+type: screening
+domain: abnormal_bp
+
+required_slots:
+  - bp_report_confirmed
+  - bp_associated_symptoms
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: abnormal_bp_screen_step1
+      goal: "Gather details about BP reading and associated symptoms"
+      tone: calm_urgent
+      must_include:
+        - "blood pressure"
+      must_ask:
+        - "What was your blood pressure reading?"
+        - "Are you having any headache, vision changes, or chest pain?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - bp_report_confirmed
+      - bp_associated_symptoms
+      - bp_systolic
+      - bp_diastolic
+      - bp_critical
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_r2: escalate_r2
+  on_low_risk: escalate_r1
+  on_unclear: escalate_r2
diff --git a/list/taxonomy/abnormal_bp/rules.yaml b/list/taxonomy/abnormal_bp/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..64343f6c47c21a77f096f7e1a2c014d2bdf900d2
--- /dev/null
+++ b/list/taxonomy/abnormal_bp/rules.yaml
@@ -0,0 +1,33 @@
+domain: abnormal_bp
+target_risk_class: R2
+
+decision_rules:
+  - id: abnormal_bp_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: abnormal_bp_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: abnormal_bp_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: abnormal_bp_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: abnormal_bp_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/abnormal_bp/triggers.yaml b/list/taxonomy/abnormal_bp/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9a6f7c076468d07978f3089f20e4193aa848b50e
--- /dev/null
+++ b/list/taxonomy/abnormal_bp/triggers.yaml
@@ -0,0 +1,75 @@
+domain: abnormal_bp
+priority: 41
+
+lexical_signals:
+  high:
+    phrases:
+      - "blood pressure readings very high at home"
+      - "blood pressure consistently above 160"
+      - "hypertensive readings at home"
+      - "blood pressure dangerously high"
+      - "BP won't come down"
+      - "blood pressure consistently elevated"
+    regex:
+      - "blood\\s+pressure.*(high|elevated|above\\s+1[6-9]\\d)"
+      - "BP.*(high|won'?t\\s+come)"
+  medium:
+    phrases:
+      - "blood pressure elevated at home"
+      - "home BP readings are high"
+      - "blood pressure not controlled"
+      - "readings above normal consistently"
+      - "blood pressure higher than usual"
+      # --- MINIMIZER coverage ---
+      - "blood pressure was a little high"
+      - "my numbers have been kind of elevated"
+      - "BP might be a bit off"
+      - "readings were a little higher than usual"
+      - "blood pressure seems higher but it's probably just stress"
+      - "machine said it was high but those things aren't always right"
+      - "numbers are up a bit"
+      - "pressure behind my eyes"
+      - "head feels kind of heavy"
+      - "felt a bit dizzy and checked my blood pressure"
+      - "took my blood pressure and it was kind of high"
+      - "blood pressure is running higher than normal"
+      - "headache and my blood pressure was up"
+      - "blood pressure is creeping up"
+      - "numbers aren't great but probably nothing"
+      - "BP has been bouncing around"
+    regex:
+      - "(blood\\s+pressure|BP|numbers|readings).{0,20}(a\\s+)?(little|bit|kind of|sort of|somewhat|slightly).{0,10}(high|elevated|up|off)"
+      - "(blood\\s+pressure|BP|numbers|readings).{0,20}(higher|up|elevated).{0,10}(than usual|than normal|lately|recently|this week)"
+      - "(blood\\s+pressure|BP).{0,20}(probably|might be|could be).{0,15}(stress|nothing|fine|okay|normal)"
+      - "(head|pressure|headache).{0,15}(heavy|pound|throb|pressure|tight).{0,20}(blood pressure|BP)"
+      - "(dizzy|lightheaded|blurry|headache).{0,25}(blood pressure|BP|check|reading|numbers)"
+      - "(machine|monitor|reading|cuff).{0,20}(said|showed|read|was).{0,15}(high|elevated|up|above)"
+      - "(took|checked|tested).{0,10}(my\\s+)?(blood\\s+pressure|BP).{0,15}(high|elevated|up|above|not great)"
+      - "(blood\\s+pressure|BP).{0,15}(creep|bounc|run|fluctuat|trend|climb).{0,10}(up|around|higher|ing)"
+      # --- specific readings ---
+      - "(blood\\s+pressure|BP|reading).{0,15}(was|is|showed|read)\\s+\\d{3}\\s*(over|/)\\s*\\d{2,3}"
+      # --- symptomatic high BP ---
+      - "(headache|vision|nosebleed|nose\\s+bleed).{0,25}(blood\\s+pressure|BP).{0,15}(high|elevated|up)"
+      # --- Reading + minimization (R2 recall) ---
+      - "(BP|blood pressure).{0,15}(\\d{2,3}).{0,30}(nothing|stress|probably|fine|okay)"
+      - "(\\d{3}).{0,10}(over|/).{0,10}(\\d{2,3}).{0,25}(probably|nothing|just|stress)"
+      - "(reading|number|BP).{0,20}(said|was|showed).{0,15}(\\d{3}).{0,20}(but|though|stress|nothing)"
+      # --- Symptom combinations with elevated reading ---
+      - "(headache|pounding|throbbing).{0,25}(elevated|high).{0,15}(reading|BP|blood pressure)"
+      - "(palpitations|racing|pounding).{0,25}(high|elevated).{0,15}(BP|blood pressure|reading)"
+      - "(dizzy|lightheaded|blurry).{0,25}(blood pressure|BP).{0,15}(checked|was|showed).{0,15}(high|elevated|\\d{3})"
+      # --- Machine skepticism with documented reading (should still escalate) ---
+      - "(machine|monitor|cuff).{0,20}(aren't|not).{0,15}(right|accurate).{0,20}(but|though|still).{0,20}(\\d{3}|high|elevated)"
+      - "(don't trust|not accurate).{0,25}(machine|monitor).{0,20}(said|showed|read).{0,15}(\\d{3}|high)"
+  low:
+    partials:
+      - "blood pressure"
+      - "BP readings"
+      - "hypertension"
+
+negation_handling:
+  patterns:
+    - "blood pressure normal"
+    - "BP is fine"
+    - "readings are good"
+  action: downgrade_confidence
diff --git a/list/taxonomy/acute_confusion/flows/clarify.yaml b/list/taxonomy/acute_confusion/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..aee5b62ad60d9d5ed71c9d3ccc8ac46f1c4ad0ea
--- /dev/null
+++ b/list/taxonomy/acute_confusion/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: acute_confusion
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: acute_confusion_clarify
+      goal: "Ask patient to describe their acute confusion symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - acute_confusion_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/acute_confusion/flows/escalate_r2.yaml b/list/taxonomy/acute_confusion/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..56453291c86b1038d498ad70ebc7e86a59e02826
--- /dev/null
+++ b/list/taxonomy/acute_confusion/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: acute_confusion
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/acute_confusion/flows/handoff.yaml b/list/taxonomy/acute_confusion/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9479c0d6b7d31d289788d2b136addf9618797f60
--- /dev/null
+++ b/list/taxonomy/acute_confusion/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: acute_confusion
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: acute_confusion_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: acute_confusion_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/acute_confusion/flows/safety_screen.yaml b/list/taxonomy/acute_confusion/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..bec88a4d2984a457c3073b7f18055e879da142d8
--- /dev/null
+++ b/list/taxonomy/acute_confusion/flows/safety_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: safety_screen
+type: screening
+domain: acute_confusion
+
+required_slots:
+  - confusion_onset
+  - orientation_status
+  - medication_changes
+  - recent_illness
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "confusion onset"
+        - "orientation status"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - confusion_onset
+      - orientation_status
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "medication changes"
+        - "recent illness"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - medication_changes
+      - recent_illness
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/list/taxonomy/acute_confusion/rules.yaml b/list/taxonomy/acute_confusion/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5e6dd70e1cf4493b0c7ecefb16eedc3aaa6f8953
--- /dev/null
+++ b/list/taxonomy/acute_confusion/rules.yaml
@@ -0,0 +1,27 @@
+domain: acute_confusion
+target_risk_class: R2
+
+decision_rules:
+  - id: acute_confusion_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: acute_confusion_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: acute_confusion_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: acute_confusion_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/acute_confusion/triggers.yaml b/list/taxonomy/acute_confusion/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ca28a619c25bf8cd7cfcf0993551b6c5dce2da30
--- /dev/null
+++ b/list/taxonomy/acute_confusion/triggers.yaml
@@ -0,0 +1,305 @@
+domain: acute_confusion
+priority: 79
+
+lexical_signals:
+  high:
+    phrases:
+      - "suddenly confused"
+      - "new confusion"
+      - "acute delirium"
+      - "suddenly not making sense"
+      - "head feels scrambled"
+      - "doesn't know where he is"
+      - "doesn't know where she is"
+      - "doesn't recognize me"
+      - "talking gibberish"
+      - "talking nonsense"
+      - "saying things that make no sense"
+      - "completely disoriented"
+      - "woke up and didn't know who I was"
+      - "can't tell me what year it is"
+      - "thinks he is somewhere else"
+      - "thinks she is somewhere else"
+      - "not making any sense at all"
+      - "hallucinating and confused"
+      - "seeing things that are not there and confused"
+      - "confused and aggressive"
+    regex:
+      - "(sudden|new|acute)\\s+(confusion|delirium)"
+      - "doesn[']?t\\s+know\\s+where\\s+(they|he|she)"
+      - "disoriented\\s+and\\s+wasn[']?t\\s+before"
+      - "don[']?t\\s+know\\s+what\\s+day"
+      - "keep\\s+forgetting\\s+what\\s+I\\s+was\\s+doing"
+      - "doesn[']?t\\s+(recognize|know)\\s+(me|us|his|her|the|where)"
+      - "talking\\s+(gibberish|nonsense|crazy|rubbish|garbage|jibberish)"
+      - "(say|said|saying)\\s+(things|stuff|words).{0,10}(that\\s+)?(make|do)n?[']?t?\\s+(no\\s+)?sense"
+      - "(complete|total)ly\\s+(disoriented|confused|out\\s+of\\s+it|lost)"
+      - "(woke|wake).{0,10}up.{0,15}(didn[']?t|doesn[']?t|not)\\s+(know|recognize)"
+      - "can[']?t\\s+tell\\s+(me|us|you).{0,10}(what|where|who|the)"
+      - "thinks?\\s+(he|she|they|I).{0,5}(is|am|are)\\s+(somewhere|in\\s+a|at\\s+the|back\\s+in)"
+      - "(hallucinat|seeing\\s+things|hearing\\s+things).{0,15}(and\\s+)?(confused|disoriented)"
+      - "(confused|disoriented).{0,15}(and\\s+)?(aggressive|agitated|combative|violent|yelling)"
+  medium:
+    phrases:
+      - "acting confused"
+      - "not themselves today"
+      - "seems disoriented"
+      - "confused since this morning"
+      - "altered mental status"
+      - "not feeling right"
+      - "walking around in a fog"
+      - "acting off"
+      - "not as sharp today"
+      - "misplacing stuff"
+      - "keeps asking the same thing"
+      - "not acting like himself"
+      - "not acting like herself"
+      - "not acting like myself"
+      - "acting really weird"
+      - "got lost in his own house"
+      - "got lost in her own house"
+      - "couldn't figure out how to use the remote"
+      - "put the milk in the cupboard"
+      - "called me by the wrong name"
+      - "forgot where the bathroom is"
+      - "staring off into space"
+      - "eyes look glazed over"
+      - "just mumbling and not making sense"
+      - "couldn't finish a sentence"
+      - "words are all jumbled up"
+      - "tried to leave the house in pajamas at 3am"
+      - "thought it was morning when it was night"
+      - "keeps getting up and wandering around"
+      - "having trouble following the conversation"
+      # --- MINIMIZER coverage ---
+      - "just a little mixed up sometimes"
+      - "a bit forgetful lately"
+      - "thoughts are kind of jumbled"
+      - "brain won't cooperate"
+      - "probably just tired"
+      - "I'm fine, just a bit foggy"
+      - "just got confused for a minute"
+      - "a little bit spacey I guess"
+      - "he's always been a little forgetful"
+      - "she's just having an off day"
+      - "my mind keeps wandering"
+      - "having a hard time concentrating"
+      - "losing my train of thought"
+      - "thoughts keep sliding around"
+      - "brain keeps skipping"
+      # --- additional patterns ---
+      - "doesn't know what year it is"
+      - "thinks the kids are still little"
+      - "talking to people who aren't here"
+      - "tried to go to a job he retired from"
+    regex:
+      - "(can[']?t|keep)\\s+(remember|recall)"
+      - "(head|brain).*(scrambled|buffering|foggy|not working)"
+      - "keep\\s+(forgetting|losing)\\s+(my\\s+)?(train\\s+of\\s+thought|what)"
+      - "can[']?t\\s+remember\\s+things\\s+today"
+      - "brain[']?s\\s+buffering"
+      - "head[']?s\\s+not\\s+working"
+      - "sounded\\s+weird\\s+on\\s+the\\s+phone"
+      - "can[']?t\\s+think\\s+straight"
+      - "doesn[']?t\\s+track"
+      - "(acting|seems?|been)\\s+(really\\s+)?(off|weird|strange)"
+      - "(my|his|her)\\s+(head|brain|mind).*(off|foggy|cloudy|fuzzy|not right|skipping)"
+      - "misplac(e|ed|ing)\\s+(my|his|her|the)"
+      - "forgot\\s+(the\\s+)?(neighbor|day|where|what|why)"
+      - "(daughter|son|wife|husband|partner|sister|spouse)\\s+(says?|keeps?\\s+saying)\\s+(I[']?m|he[']?s|she[']?s)\\s+.?off"
+      - "not\\s+acting\\s+like\\s+(my|him|her|them)sel"
+      - "mentally\\s+.?off"
+      - "couldn[']?t\\s+orient"
+      - "(asked|saying)\\s+the\\s+same\\s+(question|thing)"
+      - "rereading.*(same|email|sentence)"
+      - "brain\\s+is\\s+skipping"
+      - "speech\\s+(is\\s+)?(sort\\s+of\\s+)?jumbled"
+      - "words\\s+(are\\s+)?coming\\s+out\\s+wrong"
+      - "called\\s+the\\s+\\w+\\s+the\\s+.?(fridge|microwave|oven)"
+      - "mixed\\s+up\\s+(sometimes|on)"
+      - "she[']?s\\s+acting\\s+really\\s+weird"
+      - "he[']?s\\s+acting\\s+really\\s+weird"
+      - "(been|was)\\s+acting.*off"
+      - "acting.{0,15}off"
+      - "(spouse|partner|wife|husband)\\s+said\\s+(I|he|she)\\s+was\\s+.?weird"
+      - "kept\\s+saying\\s+(she|he)\\s+needed\\s+to"
+      - "little\\s+weird\\s+mistakes"
+      - "been\\s+retired.*go\\s+to\\s+work"
+      - "(got|get|getting)\\s+lost\\s+(in\\s+)?(his|her|the|own)\\s+(own\\s+)?(house|home|room|yard)"
+      - "(put|left|placed).{0,10}(milk|keys|phone|remote|wallet).{0,10}(in\\s+the\\s+)?(cupboard|oven|fridge|freezer|wrong|weird)"
+      - "called\\s+(me|him|her|us).{0,10}(by\\s+)?(the\\s+)?wrong\\s+name"
+      - "forgot\\s+where\\s+(the\\s+)?(bathroom|kitchen|bedroom|door)"
+      - "(star|gaz).{0,5}(ing|ed)\\s+(off|into\\s+space|at\\s+nothing|blankly)"
+      - "eyes?.{0,10}(glaz|glass|blank|vacant|empty)"
+      - "(mumbl|mutter|rambl).{0,5}(ing|ed).{0,10}(not\\s+)?(mak|no\\s+sense)"
+      - "(can[']?t|couldn[']?t|unable)\\s+(finish|complete).{0,10}(a\\s+)?(sentence|thought|word)"
+      - "words?.{0,10}(jumbl|garbl|scrambl|mix)"
+      - "(tried|try|trying)\\s+to\\s+(leave|go\\s+out|walk\\s+out).{0,15}(pajama|nightgown|underwear|naked|middle\\s+of\\s+the\\s+night|3\\s*am|2\\s*am)"
+      - "thought\\s+it\\s+was\\s+(morning|night|day|tuesday|monday|\\d{4})"
+      - "(wander|roam|pace).{0,5}(ing|ed).{0,10}(around|aimless|the\\s+house|the\\s+hall)"
+      - "(trouble|difficulty|hard\\s+time).{0,10}(follow|track|understand).{0,10}(the\\s+)?(conversation|what)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(just|only).{0,10}(a\\s+)?(little|bit|slight).{0,15}(confused|mixed up|foggy|forgetful|spacey|scattered)"
+      - "(probably|might be).{0,15}(just|nothing|tired|medication|stress|age|old|getting older)"
+      - "(confused|foggy|forgetful|mixed up).{0,15}(but|though).{0,15}(fine|okay|managing|not that bad)"
+      - "(thoughts?|brain|head|mind).{0,15}(won'?t|not|isn'?t|doesn'?t).{0,10}(cooperat|work|focus|click|connect)"
+      - "(mind|thoughts?).{0,15}(wander|drift|slide|slip|scatter|jumble|scramble|all over)"
+      - "(hard|harder|having trouble|difficulty).{0,10}(concentrat|focus|think|follow|track|keep up)"
+  low:
+    partials:
+      - "confused"
+      - "disoriented"
+      - "delirium"
+      - "altered"
+      - "not making sense"
+      - "foggy"
+      - "scrambled"
+      - "mixed up"
+      - "spacey"
+      - "out of it"
+      - "acting off"
+      - "feel off"
+      - "feels off"
+      - "glazed"
+      - "incoherent"
+      - "wandering"
+      - "mumbling"
+      - "sundowning"
+      - "not oriented"
+
+negation_handling:
+  patterns:
+    - "not confused"
+    - "thinking clearly"
+    - "mental status is fine"
+    - "I can think clearly"
+    - "head is fine"
+    - "oriented and alert"
+    - "alert and oriented"
+    - "no confusion"
+    - "confusion resolved"
+    - "back to normal mentally"
+    - "sharp as usual"
+    - "no delirium"
+    - "mind is clear"
+    - "thinking clearly now"
+    - "not confused anymore"
+    - "confusion cleared up"
+    - "brain fog lifted"
+    - "acting like themselves again"
+    - "making sense now"
+    - "remembering things fine"
+    - "knows where he is"
+    - "knows where she is"
+    - "oriented to person place and time"
+    - "mental status is back to baseline"
+    # --- non-clinical confusion context (R1 scenarios) ---
+    - "confused about the instructions"
+    - "confused about my medications"
+    - "confused about the schedule"
+    - "confused about the timing"
+    - "confused about the paperwork"
+    - "confused about which pill"
+    - "confused by all the"
+    - "confused with the"
+    - "confused about what to do"
+    - "confused about when to"
+    - "got confused about"
+    - "a little confused about"
+    - "confused about my appointment"
+    - "confused about my discharge"
+    - "I get confused with all the medical"
+    - "confusing to keep track"
+    - "it's all a bit confusing"
+    - "the instructions were confusing"
+    - "no, I'm thinking clearly"
+    - "no confusion"
+    - "not confused"
+    - "I'm clear headed"
+    - "mind is fine"
+    - "no I haven't been confused"
+    # --- medication/instruction memory context ---
+    - "remember the dosage"
+    - "remember what the doctor"
+    - "remember what to take"
+    - "remember the instructions"
+    - "remember the schedule"
+    - "remember which pill"
+    - "remember how many"
+    - "remember what I was told"
+    - "remember if I"
+    - "remember what I"
+    - "remember which"
+    - "remember what my"
+    # --- wound care / administrative confusion context ---
+    - "confused about the whole process"
+    - "confused about the process"
+    - "confused about how this works"
+    - "confused about whether"
+    - "confused about how to"
+    - "confused with forms"
+    - "confused about forms"
+    - "confused about calling"
+    - "i get confused with"
+    - "mixed up with all these appointments"
+    - "mixed up with appointments"
+    - "mixed up on how this works"
+    - "can't remember the name"
+    - "can't remember which one"
+    - "can't remember which doctor"
+    - "can't remember the doctor"
+    - "can't remember who I saw"
+    - "can't remember her name"
+    - "can't remember his name"
+    - "probably nothing"
+    - "probably just need"
+    - "probably just a general"
+    - "probably just a check"
+    - "probably just age"
+    - "wound care"
+    - "dressing change"
+    - "bandage change"
+    - "changing the bandage"
+    - "sterile gauze"
+    - "buy gauze"
+    - "healing okay"
+    - "healing fine"
+    - "healing well"
+    - "healing right"
+    - "forgetting which pill"
+    - "forgetting the schedule"
+    - "forgetting what to take"
+    - "recall the dosage"
+    - "recall what the doctor"
+    - "mixed up about my medications"
+    - "mixed up about the schedule"
+    - "mixed up about what to take"
+    - "mixed up the pills"
+    - "mixed up my medications"
+    - "pharmacy label"
+    - "label says something different"
+    - "label says"
+    - "prescription says"
+    - "the bottle says"
+    - "medication question"
+    - "medication schedule"
+    - "dosing schedule"
+    - "asking about my"
+    - "question about my"
+    - "refill"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_has_condition: ["F03.*"]
+      reason: "Baseline dementia — new confusion suggests delirium"
+    - when:
+        patient_on_medication_class: ["benzodiazepines", "opioids", "anticholinergics"]
+      reason: "High-risk medications for delirium"
diff --git a/list/taxonomy/acute_illness_preop/flows/clarify.yaml b/list/taxonomy/acute_illness_preop/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9a19e9ae6cf221b0541b69d4cf5aeda0a6a3aeda
--- /dev/null
+++ b/list/taxonomy/acute_illness_preop/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: acute_illness_preop
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: acute_illness_preop_clarify
+      goal: "Ask patient to describe how they are feeling before their surgery"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - acute_illness_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/acute_illness_preop/flows/escalate_r2.yaml b/list/taxonomy/acute_illness_preop/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1c598ce629f1252f1a358283d4b6e31a8da709d1
--- /dev/null
+++ b/list/taxonomy/acute_illness_preop/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: acute_illness_preop
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: acute_illness_preop_r2_escalation_notice
+      goal: "Inform patient that the surgical team will follow up same day about their illness before the procedure"
+      tone: calm_reassuring
+      must_include:
+        - "surgical team"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: surgical_nurse
+    urgency: same_day
+    response_spec:
+      id: acute_illness_preop_r2_handoff
+      goal: "Schedule same-day surgical team callback with illness context"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/acute_illness_preop/flows/escalate_r3.yaml b/list/taxonomy/acute_illness_preop/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..2777ec103122e3c4f2c40db5353bd471e67991c9
--- /dev/null
+++ b/list/taxonomy/acute_illness_preop/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: acute_illness_preop
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Instruct patient to call 911 immediately and inform them of nurse transfer
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/acute_illness_preop/flows/reassure_low_risk.yaml b/list/taxonomy/acute_illness_preop/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a34b1e11c70d3c0fa4f89b3cf1ffa0247a40f884
--- /dev/null
+++ b/list/taxonomy/acute_illness_preop/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: acute_illness_preop
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: acute_illness_preop_reassure
+      goal: "Acknowledge the patient's concern and note that their care team will be informed for routine follow-up before surgery"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/acute_illness_preop/flows/safety_screen.yaml b/list/taxonomy/acute_illness_preop/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f2e9eaf865c3ba7009ba4842fbbd7f2c6d739e89
--- /dev/null
+++ b/list/taxonomy/acute_illness_preop/flows/safety_screen.yaml
@@ -0,0 +1,55 @@
+flow_id: safety_screen
+type: screening
+domain: acute_illness_preop
+
+required_slots:
+  - illness_fever_present
+  - illness_respiratory_symptoms
+  - illness_gi_symptoms
+  - illness_onset_timing
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: acute_illness_preop_screen_step1
+      goal: "Assess whether the patient has a fever and respiratory symptoms"
+      tone: calm_urgent
+      must_include:
+        - "symptoms"
+      must_ask:
+        - "Do you have a fever or feel feverish?"
+        - "Are you experiencing any cough, sore throat, or trouble breathing?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - illness_fever_present
+      - illness_respiratory_symptoms
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: acute_illness_preop_screen_step2
+      goal: "Assess GI symptoms and when symptoms started"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "Have you had any nausea, vomiting, or diarrhea?"
+        - "When did you first start feeling sick?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - illness_gi_symptoms
+      - illness_onset_timing
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_r3: escalate_r3
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_r2
diff --git a/list/taxonomy/acute_illness_preop/rules.yaml b/list/taxonomy/acute_illness_preop/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e644965b64d49f097161e288634b58bec98b7441
--- /dev/null
+++ b/list/taxonomy/acute_illness_preop/rules.yaml
@@ -0,0 +1,33 @@
+domain: acute_illness_preop
+target_risk_class: R2
+
+decision_rules:
+  - id: acute_illness_preop_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: acute_illness_preop_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: acute_illness_preop_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: acute_illness_preop_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: acute_illness_preop_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/acute_illness_preop/triggers.yaml b/list/taxonomy/acute_illness_preop/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..420e3b91fe3ccf4e1ac46d52ee3b93e1e447a430
--- /dev/null
+++ b/list/taxonomy/acute_illness_preop/triggers.yaml
@@ -0,0 +1,83 @@
+domain: acute_illness_preop
+priority: 69
+
+lexical_signals:
+  high:
+    phrases:
+      - "came down with a cold before surgery"
+      - "running a fever"
+      - "started coughing"
+      - "have the flu"
+      - "stomach bug before my procedure"
+      - "feel sick before surgery"
+      - "vomiting before my surgery"
+      - "diarrhea before my procedure"
+      - "woke up with a fever this morning"
+      - "sore throat and fever before my operation"
+      - "throwing up since last night"
+      - "coughing up phlegm before surgery"
+      - "came down with something before my procedure"
+      - "been sick the last few days and surgery is soon"
+      - "got sick right before surgery"
+      - "fever of 101 and surgery is tomorrow"
+      - "been vomiting and have surgery coming up"
+      - "chills and body aches before my procedure"
+    regex:
+      - "(fever|cold|flu|cough|vomit|diarrhea|throwing\\s+up|sick|ill).{0,25}(before|prior).{0,10}(surgery|procedure|operation)"
+      - "(surgery|procedure|operation).{0,25}(fever|cold|flu|cough|vomit|diarrhea|throwing\\s+up|sick|ill)"
+      - "(came\\s+down|come\\s+down|got|gotten).{0,15}(sick|cold|flu|bug|fever|ill).{0,20}(surgery|procedure|operation)"
+      - "(running|have|got|gotten|developed).{0,10}(a\\s+)?(fever|temperature).{0,20}(surgery|procedure|operation)"
+      - "(vomit|throw|threw).{0,10}(up|ing).{0,20}(surgery|procedure|operation|before|prior)"
+      - "(diarrhea|stomach\\s+bug|stomach\\s+flu|gi\\s+bug).{0,20}(surgery|procedure|operation|before|prior)"
+      - "(?<!no )(?<!not )(fever|cough|cold|flu).{0,15}(and|with).{0,15}(surgery|procedure|operation).{0,10}(tomorrow|soon|this\\s+week|coming\\s+up)"
+  medium:
+    phrases:
+      - "not feeling well before surgery"
+      - "feeling under the weather"
+      - "sore throat before procedure"
+      - "runny nose"
+      - "congested"
+      - "body aches before surgery"
+      - "feel a little off before my procedure"
+      - "might be coming down with something"
+      - "my kid has the flu and now I feel sick"
+      - "scratchy throat before surgery"
+      - "started sneezing a lot"
+      - "headache and chills before my operation"
+      - "not sure if I should still have surgery"
+      - "feeling achy and tired before my procedure"
+    regex:
+      - "(not\\s+feeling|don't\\s+feel).{0,10}(well|good|great|right).{0,20}(surgery|procedure|operation|before)"
+      - "(under\\s+the\\s+weather|coming\\s+down\\s+with).{0,20}(surgery|procedure|operation)"
+      - "(sore\\s+throat|runny\\s+nose|congested|stuffy|sneezing|body\\s+aches).{0,20}(surgery|procedure|operation|before)"
+  low:
+    partials:
+      - "sniffles"
+      - "stuffy nose"
+      - "feeling unwell"
+      - "not well"
+      - "caught a bug"
+
+negation_handling:
+  patterns:
+    - "feeling fine"
+    - "no fever"
+    - "not sick"
+    - "healthy for surgery"
+    - "feeling great"
+    - "no cold symptoms"
+    - "no cough"
+    - "no sore throat"
+    - "not vomiting"
+    - "no diarrhea"
+    - "feeling well"
+    - "in good health"
+    - "no illness"
+    - "feel fine before surgery"
+    - "no symptoms"
+    - "cleared for surgery"
+    - "healthy and ready"
+    - "no nausea"
+    - "haven't been sick"
+    - "no body aches"
+  action: downgrade_confidence
diff --git a/list/taxonomy/acute_limb_deficit/flows/clarify.yaml b/list/taxonomy/acute_limb_deficit/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..654ac44e0c430f27b9dd0074d612ca80599bcd35
--- /dev/null
+++ b/list/taxonomy/acute_limb_deficit/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: acute_limb_deficit
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: acute_limb_deficit_clarify
+      goal: "Ask patient to describe their acute limb deficit symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - acute_limb_deficit_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/acute_limb_deficit/flows/escalate_r2.yaml b/list/taxonomy/acute_limb_deficit/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8c258c3c460ee4a5f5d1b64f7263271261dbe1a4
--- /dev/null
+++ b/list/taxonomy/acute_limb_deficit/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: acute_limb_deficit
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/acute_limb_deficit/flows/escalate_r3.yaml b/list/taxonomy/acute_limb_deficit/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1d69cb5bf59440c9a1b86a9c097e838588de8caf
--- /dev/null
+++ b/list/taxonomy/acute_limb_deficit/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: acute_limb_deficit
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Instruct patient to call 911 immediately and inform them of nurse transfer
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/acute_limb_deficit/flows/handoff.yaml b/list/taxonomy/acute_limb_deficit/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b8246e514656b21c6294a7f04c88e9551a38de4f
--- /dev/null
+++ b/list/taxonomy/acute_limb_deficit/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: acute_limb_deficit
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: acute_limb_deficit_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: acute_limb_deficit_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/acute_limb_deficit/flows/safety_screen.yaml b/list/taxonomy/acute_limb_deficit/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..bef67b9cf803030295d8084e891365874440dd67
--- /dev/null
+++ b/list/taxonomy/acute_limb_deficit/flows/safety_screen.yaml
@@ -0,0 +1,54 @@
+flow_id: safety_screen
+type: screening
+domain: acute_limb_deficit
+
+required_slots:
+  - limb_affected
+  - onset_timing
+  - sensation_status
+  - movement_ability
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "limb affected"
+        - "onset timing"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - limb_affected
+      - onset_timing
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "sensation status"
+        - "movement ability"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - sensation_status
+      - movement_ability
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/list/taxonomy/acute_limb_deficit/rules.yaml b/list/taxonomy/acute_limb_deficit/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b3b12689cd01799ffb2eb6d8b08fb0234e3d6323
--- /dev/null
+++ b/list/taxonomy/acute_limb_deficit/rules.yaml
@@ -0,0 +1,33 @@
+domain: acute_limb_deficit
+target_risk_class: R3
+
+decision_rules:
+  - id: acute_limb_deficit_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: acute_limb_deficit_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: acute_limb_deficit_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: acute_limb_deficit_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: acute_limb_deficit_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/acute_limb_deficit/triggers.yaml b/list/taxonomy/acute_limb_deficit/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..fd6d41cc0a212f47eb82fe124deb355a2754350f
--- /dev/null
+++ b/list/taxonomy/acute_limb_deficit/triggers.yaml
@@ -0,0 +1,262 @@
+domain: acute_limb_deficit
+priority: 64
+
+lexical_signals:
+  high:
+    phrases:
+      # --- original ---
+      - "can't move my leg suddenly"
+      - "arm went numb and can't use it"
+      - "sudden loss of function in my hand"
+      - "limb is cold and pale"
+      - "sudden paralysis in my arm"
+      - "can't feel my leg anymore"
+      # --- expanded naturalistic ---
+      - "my arm suddenly went dead"
+      - "my leg just gave out and I can't move it"
+      - "woke up and can't move my arm"
+      - "one side of my body stopped working"
+      - "sudden weakness on one side"
+      - "face is drooping"
+      - "half my face went numb"
+      - "can't lift my arm at all"
+      - "my leg is completely numb and won't move"
+      - "arm just went limp out of nowhere"
+      - "sudden complete weakness in my leg"
+      - "can't feel or move my hand suddenly"
+      - "I think I might be having a stroke"
+      - "one arm is totally useless now"
+      - "sudden loss of feeling and movement in leg"
+      - "my leg went cold and turned white"
+      - "arm is pale and cold and I can't move it"
+      - "face drooping and arm won't work"
+      - "speech is slurred and arm is weak"
+      # --- acute limb ischemia (6 Ps) ---
+      - "no pulse in my leg"
+      - "can't feel a pulse in my foot"
+      - "leg is cold and white and I can't feel a pulse"
+      - "my foot has no pulse and is turning blue"
+      - "pulseless leg"
+      - "leg went cold and pale and painful"
+    regex:
+      # --- original ---
+      - "sudden(ly)?\\s+(can'?t\\s+move|loss\\s+of|paralys|numb)"
+      - "limb.*(cold|pale|paralyz)"
+      # --- expanded ---
+      - "(arm|leg|hand|foot|limb)\\s+(just\\s+)?(went|gone|is)\\s+(dead|limp|numb|useless)"
+      - "can'?t\\s+(move|lift|feel|use)\\s+(my\\s+)?(arm|leg|hand|foot|left|right)"
+      - "(sudden|suddenly)\\s+(weakness|paralysis|numbness|loss)\\s+(in|of|on)"
+      - "one\\s+side\\s+(of\\s+)?(my\\s+)?(body|face)\\s+(stopped|went|is|not)\\s+(working|numb|weak|dead)"
+      - "face\\s+(is\\s+)?(drooping|droopy|sagging|numb|fallen)"
+      - "(having|think).*(stroke|CVA|\\bTIA\\b)"
+      - "(arm|leg|hand|foot)\\s+(is\\s+)?(completely|totally|entirely)\\s+(numb|weak|useless|dead|paralyz)"
+      - "(woke|wake)\\s+up.*(can'?t\\s+move|numb|paralyz|weak)"
+      - "(speech|talking)\\s+(is\\s+)?(slurred|garbled|jumbled).*(arm|leg|weak|numb)"
+      - "(pale|cold|white|blue)\\s+(and\\s+)?(can'?t\\s+move|numb|no\\s+feeling)"
+      # --- acute limb ischemia (pulselessness) ---
+      - "(no|absent|can'?t\\s+feel)\\s+(a\\s+)?(pulse|pulses)\\s+(in|on)\\s+(my\\s+)?(leg|foot|arm|hand)"
+      - "(pulseless|no\\s+pulse).{0,15}(leg|foot|arm|hand|limb)"
+      - "(leg|foot|arm|hand).{0,15}(no\\s+pulse|pulseless|cold\\s+and\\s+pale|cold\\s+and\\s+white)"
+      - "lost\\s+(all\\s+)?(feeling|function|movement|strength)\\s+in\\s+(my\\s+)?(arm|leg|hand|foot)"
+      # --- additional naturalistic ---
+      - "(leg|arm)\\s+(went|is)\\s+dead"
+      - "can'?t\\s+feel\\s+my\\s+(leg|arm)\\s+(at all|anymore|whatsoever)"
+      # --- sudden weakness patterns ---
+      - "(arm|leg|hand)\\s+(suddenly|just)\\s+(went\\s+)?(weak|limp|gave\\s+out)"
+      - "(sudden|suddenly).{0,15}(arm|leg|hand).{0,15}(weak|gave\\s+out|stopped\\s+working)"
+      # --- motor loss patterns ---
+      - "(can'?t|couldn'?t)\\s+(pick\\s+up|lift|hold|grip|squeeze|move|use).{0,15}(anything|things|my)"
+      - "(dropped|keep\\s+dropping|keeps\\s+dropping).{0,15}(everything|things|stuff)"
+      - "(arm|hand|leg|foot).{0,15}(won'?t|doesn'?t|isn'?t).{0,15}(work|move|respond|cooperate)"
+      # --- pins and needles / tingling ---
+      - "(pins\\s+and\\s+needles|tingling|prickling).{0,15}(all\\s+over|up|down|in).{0,15}(my|the)\\s+(arm|leg|hand|foot)"
+      - "(arm|leg|hand|foot).{0,15}(went|is|going).{0,15}(tingly|numb|asleep)"
+  medium:
+    phrases:
+      # --- original ---
+      - "lost feeling in my arm suddenly"
+      - "leg suddenly weak"
+      - "can't grip with my hand"
+      - "limb feels dead"
+      - "sudden weakness in one leg"
+      - "arm or leg not working"
+      # --- expanded naturalistic ---
+      - "my arm feels really weak"
+      - "having trouble gripping things"
+      - "my leg keeps giving way"
+      - "I keep dropping things"
+      - "my foot is dragging when I walk"
+      - "having difficulty walking all of a sudden"
+      - "tingling and weakness in my hand"
+      - "tingling and weakness in my arm"
+      - "tingling and weakness in my leg"
+      - "my limb feels heavy and won't work right"
+      - "arm feels like it weighs a ton"
+      - "leg feels like jelly"
+      - "having trouble lifting my arm"
+      - "my grip strength is gone"
+      - "foot drop started today"
+      - "dragging my foot when I walk"
+      - "slurred speech with arm weakness"
+      - "one hand feels clumsy and weak"
+      - "my leg buckles when I try to stand"
+      - "weakness came on pretty quickly"
+      - "trouble moving my fingers"
+      - "can't hold a cup in my hand"
+      - "my arm gave out carrying something"
+      - "pins and needles with weakness in arm"
+      - "leg not supporting my weight"
+      - "hand went tingly and now it is weak"
+      - "stumbling because my leg is weak"
+      - "balance is off and one side feels weak"
+      # --- MINIMIZER coverage ---
+      - "arm isn't cooperating like normal"
+      - "leg feels kind of off"
+      - "hand doesn't feel right"
+      - "arm feels a little different"
+      - "leg isn't quite right"
+      - "having trouble with my hand today"
+      - "arm just not working like it should"
+      # --- additional sudden weakness phrases ---
+      - "arm suddenly went weak"
+      - "leg suddenly went weak"
+      - "arm suddenly gave out"
+      - "leg suddenly gave out"
+      - "can't grip anything"
+      - "grip is gone"
+      - "can't hold things anymore"
+      - "lost strength in my arm"
+      - "lost strength in my leg"
+      - "arm went numb out of nowhere"
+      - "leg went numb out of nowhere"
+      - "can't feel my fingers"
+      - "can't feel my toes"
+      - "whole arm is numb"
+      - "whole leg is numb"
+      # --- minimizer patterns ---
+      - "arm feels a bit heavy"
+      - "leg feels a bit heavy"
+      - "arm is just a little numb"
+      - "leg is just a little numb"
+      - "hand is a little weak"
+      - "grip isn't as strong"
+      - "arm feels kind of dead"
+      - "leg feels kind of dead"
+      - "arm doesn't feel normal"
+      - "leg doesn't feel normal"
+    regex:
+      - "(arm|leg|hand|foot)\\s+(feels?|is|got|became|went|getting)\\s+(really\\s+)?(weak|heavy|tingly|numb)"
+      - "(trouble|difficulty|hard\\s+time|problem)\\s+(gripping|holding|lifting|walking|moving|standing)"
+      - "(dropping|can'?t\\s+hold|can'?t\\s+grip|can'?t\\s+grasp|couldn'?t\\s+hold)\\s+(things|objects|cup|glass|pot|mug|steady|tight)"
+      - "(leg|foot)\\s+(giving|gives|keeps\\s+giving)\\s+(out|way)"
+      - "(foot|leg)\\s+(is\\s+)?(dragging|drag)"
+      - "(tingling|pins\\s+and\\s+needles)\\s+(and|with)\\s+(weakness|weak)"
+      - "(weakness|weak)\\s+(came|started|began)\\s+(on\\s+)?(suddenly|quickly|today|fast)"
+      - "(arm|leg|hand)\\s+(gave|gives|giving)\\s+out"
+      - "(stumbling|tripping|falling|buckling)\\s+(because|due|from).*(weak|leg|foot)"
+      - "balance\\s+(is\\s+)?(off|bad|poor).*(weak|side|leg|arm)"
+      - "slurred\\s+speech\\s+(with|and)\\s+(arm|leg|weakness)"
+      - "(grip|hand).{0,15}(unreliable|giving\\s+out|not\\s+working|went\\s+weak)"
+      - "(wrist|hand|arm).{0,10}(drops|sort\\s+of\\s+drops|just\\s+drops)"
+      - "(can'?t|couldn'?t)\\s+(squeeze|grip|hold).{0,15}(hard|tight|steady|properly)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(arm|leg|hand|foot|limb).{0,20}(not right|feels? off|'s off|is off|seems? off|funny|weird|strange|different|acting up|not cooperating|not quite)"
+      - "(arm|leg|hand|foot).{0,20}(a bit|kind of|sort of|little|slightly).{0,15}(weak|numb|heavy|tingly|off)"
+      - "(clumsy|fumbl|dropping|butter.?fingers).{0,15}(today|lately|this morning|suddenly|all day)"
+      - "(hard|harder|having trouble|difficulty).{0,15}(opening|holding|gripping|walking|using|with).{0,15}(hand|arm|leg|door|jar|bottle)"
+      - "(arm|leg|hand).{0,15}(doesn'?t|isn'?t|not).{0,10}(feel|work|respond).{0,10}(right|normal|properly|the same)"
+      - "(arm|leg|hand|foot).{0,15}(feels?).{0,10}(different|weird|off|funny|wrong|not the same)"
+      # --- minimizer negation with deficit language ---
+      - "(can\\s+still|but\\s+I\\s+)?.{0,20}(arm|leg|hand|foot).{0,20}(heavy|weak|off|different)"
+      # --- vague time + deficit (confused/vague archetype) ---
+      - "(time\\s+gets|don'?t\\s+remember|mixed\\s+up).{0,30}(arm|leg|hand).{0,30}(heavy|off|weak)"
+    partials:
+      - "arm weakness"
+      - "leg weakness"
+      - "hand weakness"
+      - "foot drop"
+      - "grip weakness"
+      - "sudden tingling"
+      - "limb heaviness"
+  low:
+    partials:
+      # --- original ---
+      - "limb weakness"
+      - "sudden numbness"
+      - "paralysis"
+      - "limb deficit"
+      # --- expanded ---
+      - "hemiparesis"
+      - "hemiplegia"
+      - "paresthesia"
+      - "limb ischemia"
+      - "acute weakness"
+      - "motor deficit"
+      - "CVA"
+      - "TIA"
+      - "cerebrovascular accident"
+      - "transient ischemic attack"
+      - "acute limb ischemia"
+      - "vascular occlusion"
+      - "peripheral ischemia"
+      - "monoparesis"
+      - "focal weakness"
+      - "acute neurological deficit"
+      - "upper motor neuron"
+      - "lower motor neuron"
+      - "facial droop"
+
+negation_handling:
+  patterns:
+    # --- original ---
+    - "limbs are fine"
+    - "no weakness"
+    - "feeling normal in arms and legs"
+    # --- expanded ---
+    - "weakness from old injury"
+    - "chronic weakness"
+    - "known neuropathy"
+    - "weakness improving"
+    - "had this weakness for years"
+    - "weakness from my arthritis"
+    - "old stroke with residual weakness"
+    - "baseline weakness from prior injury"
+    - "neuropathy has been stable"
+    - "weakness is nothing new"
+    - "been weak since my surgery years ago"
+    - "no new weakness"
+    - "weakness is the same as usual"
+    - "numbness resolved"
+    - "can move all limbs normally"
+    - "strength is back to normal"
+    - "grip strength improving"
+    - "no loss of function"
+    - "tingling went away on its own"
+    - "weakness from not using it"
+    - "no acute deficit"
+    - "no focal weakness"
+    - "peripheral neuropathy stable"
+    - "weakness attributed to deconditioning"
+    - "PT says weakness is from disuse"
+    # --- R1 denial coverage ---
+    - "no arm weakness"
+    - "no leg weakness"
+    - "arms are fine"
+    - "legs are fine"
+    - "hands are fine"
+    - "feet are fine"
+    - "no numbness in arms"
+    - "no numbness in legs"
+    - "no tingling"
+    - "not weak"
+    - "not numb"
+    - "strength is fine"
+    - "can move everything fine"
+    - "no weakness in arms or legs"
+    - "arms and legs are fine"
+    - "arm is fine"
+    - "leg is fine"
+    - "hand is fine"
+    - "no arm problems"
+    - "no leg problems"
+  action: downgrade_confidence
diff --git a/list/taxonomy/acute_psychosis/flows/clarify.yaml b/list/taxonomy/acute_psychosis/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..593cfe95b920d05c3ba10e34e0792ef4fd4fcb1e
--- /dev/null
+++ b/list/taxonomy/acute_psychosis/flows/clarify.yaml
@@ -0,0 +1,27 @@
+flow_id: clarify
+type: clarification
+domain: acute_psychosis
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: psychosis_clarify
+      goal: "Gently ask patient to describe their experience"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "I want to make sure I understand what you're experiencing. Could you describe it a bit more?"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "crazy"
+        - "imagining"
+      max_questions: 1
+    collects:
+      - psychosis_clarify_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: escalate_r2
diff --git a/list/taxonomy/acute_psychosis/flows/escalate_r2.yaml b/list/taxonomy/acute_psychosis/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6c084e90672ef9f146b2f8893c65b0a3ab94d339
--- /dev/null
+++ b/list/taxonomy/acute_psychosis/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: acute_psychosis
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: psychosis_r2_escalation_notice
+      goal: "Connect patient with psychiatric professional for evaluation"
+      tone: empathetic
+      must_include:
+        - "psychiatric"
+        - "support"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "crazy"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: psychiatric_professional
+    urgency: same_day
+    response_spec:
+      id: psychosis_r2_handoff
+      goal: "Transfer to psychiatric professional"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/acute_psychosis/flows/escalate_r3.yaml b/list/taxonomy/acute_psychosis/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ac29774956c11d61a8aa5b42871db0585b36dc27
--- /dev/null
+++ b/list/taxonomy/acute_psychosis/flows/escalate_r3.yaml
@@ -0,0 +1,39 @@
+flow_id: escalate_r3
+type: escalation
+domain: acute_psychosis
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: psychosis_r3_escalation_notice
+    goal: Command hallucinations or danger — immediate crisis intervention
+    tone: calm_urgent
+    must_include:
+    - '988'
+    - call 911
+    - right now
+    - crisis
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - crazy
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: crisis_counselor
+  urgency: immediate
+  response_spec:
+    id: psychosis_r3_handoff
+    goal: Transfer to crisis counselor
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/acute_psychosis/flows/safety_screen.yaml b/list/taxonomy/acute_psychosis/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4d9104275036f68e79763d8b1091a1e6fd319891
--- /dev/null
+++ b/list/taxonomy/acute_psychosis/flows/safety_screen.yaml
@@ -0,0 +1,58 @@
+flow_id: safety_screen
+type: screening
+domain: acute_psychosis
+
+required_slots:
+  - psychosis_type
+  - command_hallucinations
+  - danger_to_self_others
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: psychosis_screen_step1
+      goal: "Determine type of psychotic experience and check for command hallucinations"
+      tone: gentle_professional
+      must_include:
+        - "understand"
+        - "safe"
+      must_ask:
+        - "Can you tell me more about what you're experiencing?"
+        - "If you're hearing voices, are they telling you to hurt yourself or anyone else?"
+      must_not:
+        - "don't worry"
+        - "diagnos"
+        - "crazy"
+        - "imagining"
+      max_questions: 2
+    collects:
+      - psychosis_type
+      - command_hallucinations
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: psychosis_screen_step2
+      goal: "Assess danger to self or others and onset timing"
+      tone: gentle_professional
+      must_include:
+        - "important"
+      must_ask:
+        - "Do you feel like you might hurt yourself or someone else?"
+        - "When did this start — is this new or has it been going on for a while?"
+      must_not:
+        - "don't worry"
+        - "diagnos"
+        - "crazy"
+      max_questions: 2
+    collects:
+      - danger_to_self_others
+      - psychosis_onset
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_r2: escalate_r2
+  on_low_risk: escalate_r2
+  on_unclear: escalate_r2
diff --git a/list/taxonomy/acute_psychosis/rules.yaml b/list/taxonomy/acute_psychosis/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a5b6967c494c62a0e3071c8420ae8f30b6996d53
--- /dev/null
+++ b/list/taxonomy/acute_psychosis/rules.yaml
@@ -0,0 +1,33 @@
+domain: acute_psychosis
+target_risk_class: R2
+
+decision_rules:
+  - id: psychosis_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: psychosis_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: psychosis_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: psychosis_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: psychosis_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/acute_psychosis/triggers.yaml b/list/taxonomy/acute_psychosis/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4057fe06bc9f7f47ace86013b33c651f85fb31df
--- /dev/null
+++ b/list/taxonomy/acute_psychosis/triggers.yaml
@@ -0,0 +1,68 @@
+domain: acute_psychosis
+priority: 75
+
+lexical_signals:
+  high:
+    phrases:
+      - "hearing voices telling me to hurt"
+      - "voices telling me to kill"
+      - "seeing things that aren't there"
+      - "they're trying to poison me"
+      - "they're trying to kill me"
+      - "people are following me"
+      - "someone put a chip in me"
+      - "the government is watching me"
+      - "voices telling me to do things"
+      - "I see people who aren't there"
+      - "I'm getting messages from the TV"
+    regex:
+      - "(hear|hearing)\\s+(voice|voices)\\s+(tell|telling|command|ordering)\\s+(me|him|her)\\s+to\\s+(hurt|kill|harm|attack)"
+      - "(see|seeing)\\s+(things|people|shadow|figure).{0,15}(aren'?t|not)\\s+(there|real)"
+      - "(try|trying|going|want)\\s+to\\s+(poison|kill|control|track|follow)\\s+me"
+      - "(chip|device|tracker|transmitter)\\s+(in|inside|implanted)"
+  medium:
+    phrases:
+      - "hearing voices"
+      - "seeing things"
+      - "paranoid"
+      - "everyone is watching me"
+      - "I see shadow people"
+      - "the voices say"
+      - "voices in my head"
+      - "people aren't who they say they are"
+      - "things aren't real"
+      - "can't tell what's real"
+      - "losing touch with reality"
+      - "thought broadcasting"
+      - "they can read my thoughts"
+    regex:
+      - "(hear|hearing)\\s+(voice|voices)"
+      - "(see|seeing)\\s+(shadow|thing|people|figure)s?\\s+(that|who)\\s+(aren'?t|not|don'?t)"
+      - "(everyone|they|people|somebody)\\s+(is|are)\\s+(watching|following|tracking|monitoring|listening)"
+      - "(can'?t|cannot)\\s+tell\\s+(what'?s|if.{0,10}(is))\\s+real"
+      - "(losing|lost)\\s+touch\\s+(with\\s+)?reality"
+      - "(read|reading|hear|know)\\s+my\\s+thoughts"
+  low:
+    partials:
+      - "hallucinating"
+      - "psychotic"
+      - "delusional"
+      - "psychosis"
+      - "voices"
+      - "paranoia"
+      - "delusions"
+      - "hallucinations"
+
+negation_handling:
+  patterns:
+    - "not hearing voices anymore"
+    - "used to see things"
+    - "no longer hallucinating"
+    - "hallucinations stopped"
+    - "voices went away"
+    - "medication is working for the voices"
+    - "paranoia is better"
+    - "watched a movie about"
+    - "read about psychosis"
+    - "asking about hallucinations"
+  action: downgrade_confidence
diff --git a/list/taxonomy/airway_compromise/flows/clarify.yaml b/list/taxonomy/airway_compromise/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..425ce8f8b80978c7062f86f6804615726b445a38
--- /dev/null
+++ b/list/taxonomy/airway_compromise/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: airway_compromise
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: airway_compromise_clarify
+      goal: "Ask patient to describe their airway compromise symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - airway_compromise_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/airway_compromise/flows/escalate_r3.yaml b/list/taxonomy/airway_compromise/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7ff6ee80ea5c8cf90794646e6e6355ada9e2c57c
--- /dev/null
+++ b/list/taxonomy/airway_compromise/flows/escalate_r3.yaml
@@ -0,0 +1,38 @@
+flow_id: escalate_r3
+type: escalation
+domain: airway_compromise
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Inform patient this requires immediate clinical attention and they will
+      be transferred
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/airway_compromise/flows/handoff.yaml b/list/taxonomy/airway_compromise/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..45a7af4d3ea8371ec00430846380334721b1ff22
--- /dev/null
+++ b/list/taxonomy/airway_compromise/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: airway_compromise
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: airway_compromise_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: airway_compromise_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/airway_compromise/rules.yaml b/list/taxonomy/airway_compromise/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ee128b4f2551883d5bbd0ad10da2ff8ac7fa5d2d
--- /dev/null
+++ b/list/taxonomy/airway_compromise/rules.yaml
@@ -0,0 +1,21 @@
+domain: airway_compromise
+target_risk_class: R3
+
+decision_rules:
+  - id: airway_compromise_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r3
+
+  - id: airway_compromise_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r3
+
+  - id: airway_compromise_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/airway_compromise/triggers.yaml b/list/taxonomy/airway_compromise/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..12c4938cfe588665eed7654557bfe59e7e904e17
--- /dev/null
+++ b/list/taxonomy/airway_compromise/triggers.yaml
@@ -0,0 +1,104 @@
+domain: airway_compromise
+priority: 97
+
+lexical_signals:
+  high:
+    phrases:
+      - "choking"
+      - "can't swallow"
+      - "something stuck in throat"
+      - "stridor"
+      - "airway blocked"
+      - "can't get air in"
+      - "throat closing up"
+      - "throat is closing"
+      - "throat feels tight"
+      - "throat is getting tight"
+      - "throat is swelling"
+    regex:
+      - "(choking|airway)\\s+(on|blocked|compromis)"
+      - "throat\\s+(closing|swelling|tight|narrowing)"
+      - "throat.{0,15}(tight|closing|swelling|narrow|block|squeez)"
+      - "(tight|closing|swelling|squeez).{0,15}(in\\s+)?(my\\s+)?throat"
+      - "(can'?t|hard(er)?\\s+to|difficult\\s+to)\\s+(swallow|get\\s+air|pull\\s+air)"
+      - "(hard|difficult|harder).{0,10}(to\\s+)?(swallow|pull\\s+air)"
+      # --- cyanosis ---
+      - "(lips?|face|fingers?|skin).{0,10}(turning|turned|is|are|look|looks|getting).{0,10}(blue|bluish|purple|gray|grey|cyanotic)"
+      - "(blue|bluish|purple|cyanotic).{0,15}(lips?|face|around (the )?mouth|fingers?)"
+      - "(purple|blue|dusky).{0,10}(around|near).{0,10}(mouth|lips?)"
+      # --- choking behaviors ---
+      - "(grabbing|clutching|holding|hands? on|reaching for).{0,10}(throat|neck)"
+      - "(can'?t|unable to|not able to).{0,10}(talk|speak|say anything|get words out)"
+      - "(gasping|gulping|fighting).{0,10}(for)?.{0,5}(air|breath)"
+      - "making.{0,10}(no sound|silent)"
+      # --- voice changes ---
+      - "voice.{0,15}(disappeared|gone|lost|hoarse|raspy|changed|different)"
+      - "(can barely|barely can).{0,10}(speak|talk|get words)"
+      - "(stridor|wheez|whistle).{0,15}(when|every time).{0,10}(breath|inhal)"
+      # --- witnessed events ---
+      - "(choking|choked).{0,15}(on|while eating).{0,15}(food|eating|meat|steak|chicken|bone|candy|pill)"
+      - "(something|food|pill|bone).{0,15}(stuck|lodged).{0,15}(in|down).{0,10}(throat|airway|windpipe)"
+      - "(swallowed|ate|inhaled).{0,15}(wrong way|down wrong|went down wrong)"
+  medium:
+    phrases:
+      - "difficulty swallowing and can't breathe"
+      - "throat feels blocked"
+      - "gagging and can't breathe"
+      - "food stuck in airway"
+      - "noisy breathing"
+      - "wheezing severely"
+      - "breathing weird"
+      - "harder to pull air in"
+      - "chest is tight and can't breathe"
+      - "throat feels like it's getting tight"
+      - "voice sounds weird"
+      - "voice is hoarse"
+      - "voice sounds muffled"
+      - "lips feel puffy"
+      - "high-pitched sound when I breathe"
+      - "high-pitched sound when I inhale"
+      - "the space is narrowing"
+    regex:
+      - "throat.{0,20}(block|weird|funny|strange|off)"
+      - "(noisy|loud|wheez|raspy|ragged).{0,10}breath"
+      - "(voice|speaking).{0,25}(weird|hoarse|raspy|strange|different|funny|muffled|thick)"
+      - "breath.{0,10}(weird|strange|noisy|loud|funny)"
+      - "(high.{0,5}pitched|whistl).{0,15}(sound|noise|when\\s+I\\s+(breath|inhal))"
+      - "(space|airway).{0,10}(narrowing|closing|getting\\s+smaller|shrinking)"
+      - "(lips?|tongue|face).{0,15}(puffy|swelling|swollen|bigger|tingly|blue|bluish|purple|cyanotic|discolored)"
+      # --- caregiver report ---
+      - "(they|he|she)\\s+(can'?t|is not|isn'?t)\\s+(breathe|breathing|getting air)"
+      - "(choking|turning)\\s+(and\\s+)?(blue|purple|gray|cyanotic)"
+      - "(drooling|can'?t swallow)\\s+(and\\s+)?(can'?t|not|hard to)\\s+(breathe|talk|speak)"
+      # --- from missed scenarios analysis ---
+      - "(wheez|wheeze|wheezing).{0,30}(worse|terrible|awful|severe|getting|bad)"
+      - "(lips?|mouth).{0,15}(look|are|turned|turning|seem).{0,15}(blue|bluish|purple|gray|cyanotic)"
+      - "(grab|clutch|hold|pulling|clawing).{0,15}(at\\s+)?(throat|neck)"
+      - "(can\\s+barely|barely\\s+can)\\s+(breathe|get air|talk|speak|get words)"
+      - "(labored|struggling|heaving|gasping|working hard).{0,15}(breath|to breathe|breathing)"
+      - "(awful|terrible|horrible|scary).{0,15}(sound|noise).{0,20}(breath|wheez)"
+      - "(straw|pinhole|narrow).{0,20}(breath|breathing|air)"
+      - "(chest|ribs?).{0,10}(heaving|working hard|retracting|pulling in)"
+  low:
+    partials:
+      - "stridor"
+      - "airway"
+      - "choking"
+      - "obstructed"
+      - "throat tight"
+      - "swallowing difficulty"
+
+negation_handling:
+  patterns:
+    - "not choking"
+    - "can swallow fine"
+    - "throat is clear"
+    - "airway is fine"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
diff --git a/list/taxonomy/anaphylaxis/flows/clarify.yaml b/list/taxonomy/anaphylaxis/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..97425e214b3e7ba09563fee0b396daa889f6962e
--- /dev/null
+++ b/list/taxonomy/anaphylaxis/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: anaphylaxis
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: anaphylaxis_clarify
+      goal: "Ask patient to describe their anaphylaxis symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - anaphylaxis_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/anaphylaxis/flows/escalate_r3.yaml b/list/taxonomy/anaphylaxis/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b2e92e8d9748f432d8410f7ac778716910970741
--- /dev/null
+++ b/list/taxonomy/anaphylaxis/flows/escalate_r3.yaml
@@ -0,0 +1,38 @@
+flow_id: escalate_r3
+type: escalation
+domain: anaphylaxis
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Inform patient this requires immediate clinical attention and they will
+      be transferred
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/anaphylaxis/flows/handoff.yaml b/list/taxonomy/anaphylaxis/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e1704fb68f44ab6fd369e8da3928e5d24892f22e
--- /dev/null
+++ b/list/taxonomy/anaphylaxis/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: anaphylaxis
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: anaphylaxis_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: anaphylaxis_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/anaphylaxis/flows/reassure_low_risk.yaml b/list/taxonomy/anaphylaxis/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8b34930aa1cb2eec5d2a15a84df6bc09585ba2ff
--- /dev/null
+++ b/list/taxonomy/anaphylaxis/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: anaphylaxis
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: anaphylaxis_reassure
+      goal: "Acknowledge the patient's concern about an allergic reaction, note that their care team will be informed for routine follow-up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/anaphylaxis/flows/safety_screen.yaml b/list/taxonomy/anaphylaxis/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c711d07c8f67071c1e01cbf8327b5b5eaa31c7c6
--- /dev/null
+++ b/list/taxonomy/anaphylaxis/flows/safety_screen.yaml
@@ -0,0 +1,54 @@
+flow_id: safety_screen
+type: screening
+domain: anaphylaxis
+
+required_slots:
+  - rash_hives
+  - tongue_lip_swelling
+  - breathing_difficulty_acute
+  - exposure_trigger
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: anaphylaxis_screen_step1
+      goal: "Determine whether the patient has visible allergic reaction signs"
+      tone: calm_urgent
+      must_include:
+        - "reaction"
+      must_ask:
+        - "Do you have any rash, hives, or skin changes right now?"
+        - "Is your tongue, lips, or throat feeling swollen?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - rash_hives
+      - tongue_lip_swelling
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: anaphylaxis_screen_step2
+      goal: "Screen for respiratory compromise and identify trigger"
+      tone: calm_urgent
+      must_include:
+        - "important"
+      must_ask:
+        - "Are you having any difficulty breathing right now?"
+        - "Did you eat anything new or get exposed to something unusual recently?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - breathing_difficulty_acute
+      - exposure_trigger
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_r3
diff --git a/list/taxonomy/anaphylaxis/rules.yaml b/list/taxonomy/anaphylaxis/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..982be7ad37e23cc8a0684900e4d911216de9d3b8
--- /dev/null
+++ b/list/taxonomy/anaphylaxis/rules.yaml
@@ -0,0 +1,27 @@
+domain: anaphylaxis
+target_risk_class: R3
+
+decision_rules:
+  - id: anaphylaxis_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: anaphylaxis_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: anaphylaxis_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: anaphylaxis_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
diff --git a/list/taxonomy/anaphylaxis/triggers.yaml b/list/taxonomy/anaphylaxis/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d38d36cce3c3b3e9ba5aeeca035cdec55764153e
--- /dev/null
+++ b/list/taxonomy/anaphylaxis/triggers.yaml
@@ -0,0 +1,149 @@
+domain: anaphylaxis
+priority: 92
+
+lexical_signals:
+  high:
+    phrases:
+      - "throat is swelling shut"
+      - "can't breathe allergic reaction"
+      - "anaphylaxis"
+      - "tongue is swelling"
+      - "severe allergic reaction"
+      - "used my epipen"
+      - "whole body hives and can't breathe"
+      - "throat feels tight"
+      - "lips are swelling"
+      - "face is swelling"
+    regex:
+      - "(throat|tongue)\\s+(is\\s+)?swelling"
+      - "anaphyla"
+      - "(throat|face|lips|tongue).{0,15}(swell|puff|tight|clos)"
+      - "(allergic|allergy|reaction).{0,30}(throat|swell|breathing|breathe|hives)"
+      - "(hives|rash|itchy|blotch).{0,30}(throat|swell|breathing|breathe|tight)"
+      - "(can'?t|hard\\s+to|difficult).{0,10}(swallow|breathe).{0,20}(allerg|reaction|ate|food|shrimp|nut|peanut)"
+  medium:
+    phrases:
+      - "allergic reaction with swelling"
+      - "hives spreading everywhere"
+      - "difficulty swallowing after allergic reaction"
+      - "allergic reaction getting worse"
+      - "swelling face"
+      - "face feels hot and puffy"
+      - "itchy and throat tight"
+      - "harder to swallow"
+      - "voice sounds weird"
+      - "rash and my throat"
+      - "blotchy and itchy"
+      - "ate something and now throat"
+      # --- MINIMIZER coverage ---
+      - "voice sounds funny to me"
+      - "keep clearing my throat"
+      - "feels like I have to think about breathing"
+      - "red bumpy stuff on my arms"
+      - "skin is breaking out"
+      - "kind of shaky and weird"
+      - "stomach feels off after eating"
+    regex:
+      - "(ate|eaten|food|shrimp|nut|peanut|shellfish).{0,40}(throat|swell|hives|rash|itch|react)"
+      - "(throat|swell|hives|rash|itch|react).{0,40}(ate|eaten|food|shrimp|nut|peanut|shellfish)"
+      - "(face|skin).{0,15}(hot|puffy|swollen|blotchy|flushed)"
+      - "(hives|rash|itch|welt).{0,20}(spread|everywhere|worse|getting)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(voice|throat).{0,15}(funny|weird|off|different|strange|hoarse|scratchy|thick)"
+      - "(hard|harder|difficult|tough).{0,10}(to\\s+)?(breathe|breathing|swallow|catch).{0,10}(breath)?"
+      - "(red|bump|hive|welt|itch|rash|blotch).{0,15}(arm|body|skin|everywhere|spreading|neck|chest|stomach)"
+      - "\\b(shaky|dizzy|weird|funny)\\b.{0,25}\\b(ate|eat|eaten|eating|food|lunch|dinner|sting|stung|bitten)\\b"
+      - "\\b(ate|eat|eaten|eating|food|sting|stung|bitten)\\b.{0,25}\\b(shaky|dizzy|weird|funny|stomach|nausea|throw)\\b"
+      - "can'?t.{0,10}(take|get).{0,10}(deep|full).{0,10}breath"
+      - "(lip|face|tongue|eye).{0,15}(puffy|puff|swell|swollen|bigger|fat|tingle)"
+      - "(throat|voice).{0,15}(closing|tightening|getting tight|swelling|feels tight)"
+  low:
+    partials:
+      - "epipen"
+      - "anaphylaxis"
+
+negation_handling:
+  patterns:
+    - "no allergic reaction"
+    - "allergy under control"
+    - "reaction cleared up"
+    - "hives resolved"
+    - "hives went away"
+    - "mild allergic reaction"
+    - "no throat swelling"
+    - "breathing fine"
+    # --- R1 denial coverage ---
+    - "no hives"
+    - "no rash"
+    - "no swelling"
+    - "not swollen"
+    - "no itching"
+    - "not itchy"
+    - "no difficulty breathing"
+    - "no trouble breathing"
+    - "no allergic symptoms"
+    - "not having an allergic reaction"
+    - "no bumps"
+    - "no welts"
+    # --- mild medication side effect context ---
+    - "just a rash"
+    - "mild rash"
+    - "small rash"
+    - "a few blotches"
+    - "just itchy"
+    - "just some bumps"
+    - "little hives"
+    - "minor reaction"
+    - "mild reaction"
+    - "skin reaction"
+    - "just a skin thing"
+    - "not severe"
+    - "can breathe fine"
+    - "breathing is fine"
+    - "throat is fine"
+    - "no throat swelling"
+    - "swallowing fine"
+    - "can swallow fine"
+    - "no trouble swallowing"
+    - "face is fine"
+    - "no facial swelling"
+    - "just on my arms"
+    - "just on my skin"
+    - "topical only"
+    - "localized rash"
+    - "contact rash"
+    - "no wheezing"
+    - "started a new medication"
+    - "started a new antibiotic"
+    - "started a new blood pressure"
+    - "started a new prescription"
+    - "started taking"
+    - "since starting the new"
+    - "since I started the"
+    - "after the new medication"
+    - "after starting the"
+    - "side effect"
+    - "drug reaction"
+    - "medication side effect"
+    - "known side effect"
+    - "common reaction"
+    - "happened before with"
+    - "question about my medication"
+    - "question about my allergy"
+    - "allergy medication"
+    - "taking benadryl"
+    - "took an antihistamine"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_has_condition: ["T78.2*", "Z88.*"]
+      reason: "Known severe allergy history"
diff --git a/list/taxonomy/anticoagulant_hold_failure/flows/clarify.yaml b/list/taxonomy/anticoagulant_hold_failure/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..2befd16b0218c933910f65c9e0dabf4f83032d97
--- /dev/null
+++ b/list/taxonomy/anticoagulant_hold_failure/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: anticoagulant_hold_failure
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: anticoag_hold_clarify
+      goal: "Ask patient to describe their blood thinner concern more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - anticoag_hold_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/anticoagulant_hold_failure/flows/escalate_r2.yaml b/list/taxonomy/anticoagulant_hold_failure/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7baa8d0c3c569c7bd3a9a6403d770e7ad810322c
--- /dev/null
+++ b/list/taxonomy/anticoagulant_hold_failure/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: anticoagulant_hold_failure
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: anticoag_hold_r2_escalation_notice
+      goal: "Inform patient that a surgical nurse will follow up same day about their blood thinner status"
+      tone: calm_reassuring
+      must_include:
+        - "surgical nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: surgical_nurse
+    urgency: same_day
+    response_spec:
+      id: anticoag_hold_r2_handoff
+      goal: "Schedule same-day surgical nurse callback with blood thinner context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/anticoagulant_hold_failure/flows/escalate_r3.yaml b/list/taxonomy/anticoagulant_hold_failure/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c1f326082a6c39796abff76ada0f0e5e5541e240
--- /dev/null
+++ b/list/taxonomy/anticoagulant_hold_failure/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: anticoagulant_hold_failure
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Instruct patient to call 911 immediately and inform them of nurse transfer
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/anticoagulant_hold_failure/flows/reassure_low_risk.yaml b/list/taxonomy/anticoagulant_hold_failure/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..cf94c85c0f5328d104f7267f02f3d8ecd0989232
--- /dev/null
+++ b/list/taxonomy/anticoagulant_hold_failure/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: anticoagulant_hold_failure
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: anticoag_hold_reassure
+      goal: "Acknowledge the patient followed their blood thinner hold instructions correctly and note their care team will be informed"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/anticoagulant_hold_failure/flows/safety_screen.yaml b/list/taxonomy/anticoagulant_hold_failure/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c572c20c8e39a2df16e7c0c6757a72fd3860ce83
--- /dev/null
+++ b/list/taxonomy/anticoagulant_hold_failure/flows/safety_screen.yaml
@@ -0,0 +1,52 @@
+flow_id: safety_screen
+type: screening
+domain: anticoagulant_hold_failure
+
+required_slots:
+  - anticoag_still_taking
+  - anticoag_last_dose
+  - surgery_date_aware
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: anticoag_hold_screen_step1
+      goal: "Determine whether the patient is still taking their anticoagulant and when the last dose was"
+      tone: calm_urgent
+      must_include:
+        - "blood thinner"
+      must_ask:
+        - "Are you still taking your blood thinner?"
+        - "When was your last dose?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - anticoag_still_taking
+      - anticoag_last_dose
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: anticoag_hold_screen_step2
+      goal: "Confirm the patient knows their surgery date and timing"
+      tone: calm_urgent
+      must_include:
+        - "surgery"
+      must_ask:
+        - "When is your surgery scheduled?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 1
+    collects:
+      - surgery_date_aware
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_r3: escalate_r3
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_r2
diff --git a/list/taxonomy/anticoagulant_hold_failure/rules.yaml b/list/taxonomy/anticoagulant_hold_failure/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e7bc77923e4f940eb58a461b5d8c1841cd6e3c8f
--- /dev/null
+++ b/list/taxonomy/anticoagulant_hold_failure/rules.yaml
@@ -0,0 +1,33 @@
+domain: anticoagulant_hold_failure
+target_risk_class: R2
+
+decision_rules:
+  - id: anticoagulant_hold_failure_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: anticoagulant_hold_failure_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: anticoagulant_hold_failure_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: anticoagulant_hold_failure_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: anticoagulant_hold_failure_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/anticoagulant_hold_failure/triggers.yaml b/list/taxonomy/anticoagulant_hold_failure/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..2b4990e96979a24abe3fa2cfb8c10ea941db68f6
--- /dev/null
+++ b/list/taxonomy/anticoagulant_hold_failure/triggers.yaml
@@ -0,0 +1,101 @@
+domain: anticoagulant_hold_failure
+priority: 71
+
+lexical_signals:
+  high:
+    phrases:
+      - "still taking my warfarin"
+      - "forgot to stop blood thinner"
+      - "didn't stop my eliquis"
+      - "took my blood thinner this morning"
+      - "still on coumadin"
+      - "haven't stopped the blood thinner"
+      - "took xarelto today"
+      - "forgot about the blood thinner hold"
+      - "still taking my anticoagulant"
+      - "took my blood thinner yesterday too"
+      - "didn't realize I was supposed to stop"
+      - "nobody told me to stop the blood thinner"
+      - "been taking it every day including today"
+      - "took my warfarin last night"
+      - "took eliquis this morning before I remembered"
+      - "still on my blood thinner and surgery is tomorrow"
+      - "I forgot to hold the coumadin"
+      - "took pradaxa this morning"
+    regex:
+      - "(still|kept|continue|continu)\\s+(tak|on|us).{0,20}(warfarin|eliquis|xarelto|coumadin|pradaxa|blood\\s+thinner|anticoagul)"
+      - "(warfarin|eliquis|xarelto|coumadin|pradaxa|blood\\s+thinner).{0,25}(still|forgot|didn't\\s+stop|haven't\\s+stop|took|taking)"
+      - "(forgot|forget|didn't|did\\s+not|haven't).{0,20}(stop|hold|discontinue).{0,15}(warfarin|eliquis|xarelto|coumadin|pradaxa|blood\\s+thinner|anticoagul)"
+      - "took.{0,15}(warfarin|eliquis|xarelto|coumadin|pradaxa|blood\\s+thinner).{0,15}(this\\s+morning|today|last\\s+night|yesterday)"
+      - "(warfarin|eliquis|xarelto|coumadin|pradaxa|blood\\s+thinner).{0,15}(this\\s+morning|today|last\\s+night|yesterday)"
+      - "(?<!stopped )(?<!held )(?<!off )(blood\\s+thinner|anticoagul).{0,20}(before|prior).{0,10}(surgery|procedure|operation)"
+  medium:
+    phrases:
+      - "blood thinner question"
+      - "when do I stop my warfarin"
+      - "my blood thinner"
+      - "anticoagulant instructions"
+      - "when should I stop eliquis"
+      - "blood thinner and surgery"
+      - "question about my coumadin"
+      - "hold instructions for blood thinner"
+      - "confused about the blood thinner hold"
+      - "not sure when to stop the blood thinner"
+      - "blood thinner before my procedure"
+    partials:
+      - "warfarin"
+      - "eliquis"
+      - "xarelto"
+      - "coumadin"
+      - "pradaxa"
+      - "blood thinner"
+      - "anticoagulant hold"
+      - "blood thinner hold"
+  low:
+    partials:
+      - "thin blood"
+      - "anti-clotting"
+      - "blood medication"
+      - "clotting medication"
+
+negation_handling:
+  patterns:
+    - "stopped my blood thinner"
+    - "held my warfarin"
+    - "off the blood thinner"
+    - "stopped it as instructed"
+    - "haven't taken it since"
+    - "followed the hold instructions"
+    - "stopped taking my eliquis"
+    - "held the coumadin"
+    - "off the xarelto"
+    - "stopped the blood thinner as told"
+    - "last dose was five days ago"
+    - "stopped it a week ago"
+    - "held the anticoagulant"
+    - "followed the instructions to stop"
+    - "not on any blood thinners"
+    - "no blood thinners"
+    - "don't take blood thinners"
+    - "never been on blood thinners"
+    - "stopped warfarin last week"
+    - "off coumadin for five days"
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_on_medication: ["warfarin", "eliquis", "xarelto", "coumadin", "pradaxa"]
+      reason: "Patient actively on anticoagulant -- hold failure risk confirmed"
+    - when:
+        patient_on_medication_class: ["anticoagulant", "DOAC"]
+      reason: "Patient on anticoagulant class -- hold failure risk confirmed"
+  boost_to_medium:
+    - when:
+        medication_count_above: 10
+      reason: "Polypharmacy patient -- higher risk of medication management error"
+  suppress:
+    - when:
+        patient_on_medication: ["aspirin"]
+        patient_on_medication_class: ["antiplatelet"]
+      reason: "Patient on antiplatelet not anticoagulant -- hold failure not applicable"
diff --git a/list/taxonomy/anticoagulation_monitoring/flows/clarify_anticoag.yaml b/list/taxonomy/anticoagulation_monitoring/flows/clarify_anticoag.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..886407e09271e84b56d89dd5d2bbd919ff7d0365
--- /dev/null
+++ b/list/taxonomy/anticoagulation_monitoring/flows/clarify_anticoag.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify_anticoag
+type: clarification
+domain: anticoagulation_monitoring
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: anticoagulation_monitoring_clarify
+      goal: "Ask patient to describe their anticoagulation concern more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - anticoagulation_monitoring_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/anticoagulation_monitoring/flows/escalate_anticoag.yaml b/list/taxonomy/anticoagulation_monitoring/flows/escalate_anticoag.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..27e8baf5ddd6d86e109256ce1217c4b3d85fc567
--- /dev/null
+++ b/list/taxonomy/anticoagulation_monitoring/flows/escalate_anticoag.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_anticoag
+type: escalation
+domain: anticoagulation_monitoring
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: anticoag_r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their anticoagulation concern"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: anticoag_r2_handoff
+      goal: "Schedule same-day nurse callback with anticoagulation monitoring context"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/anticoagulation_monitoring/flows/escalate_r2.yaml b/list/taxonomy/anticoagulation_monitoring/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3087452b3ed66754df0c424584fdaf8406ea648a
--- /dev/null
+++ b/list/taxonomy/anticoagulation_monitoring/flows/escalate_r2.yaml
@@ -0,0 +1,24 @@
+flow_id: escalate_r2
+type: escalation
+domain: anticoagulation_monitoring
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient about urgency of their anticoagulation concern and transfer to a clinical team member for same-day follow-up"
+      tone: calm_direct
+      must_include:
+        - "nurse"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably nothing"
+        - "wait and see"
+      max_questions: 0
+
+exit:
+  on_complete: handoff
diff --git a/list/taxonomy/anticoagulation_monitoring/flows/escalate_r3.yaml b/list/taxonomy/anticoagulation_monitoring/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..beb3f4fd3061e5e25b55ae1b2648e3552b8a0b1b
--- /dev/null
+++ b/list/taxonomy/anticoagulation_monitoring/flows/escalate_r3.yaml
@@ -0,0 +1,27 @@
+flow_id: escalate_r3
+type: escalation
+domain: anticoagulation_monitoring
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: anticoag_r3_escalation_notice
+    goal: Instruct patient to call 911 or go to the emergency department immediately
+      for severe or uncontrolled bleeding on anticoagulation
+    tone: calm_urgent
+    must_include:
+    - call 911
+    - emergency
+    - right away
+    - bleeding
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - wait
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+exit:
+  on_complete: end
diff --git a/list/taxonomy/anticoagulation_monitoring/flows/handoff.yaml b/list/taxonomy/anticoagulation_monitoring/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..eec91a51f4ac13d2fcb1b6a6cd56f360691bbb9a
--- /dev/null
+++ b/list/taxonomy/anticoagulation_monitoring/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: anticoagulation_monitoring
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: anticoagulation_monitoring_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: anticoagulation_monitoring_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/anticoagulation_monitoring/flows/reassure_anticoag.yaml b/list/taxonomy/anticoagulation_monitoring/flows/reassure_anticoag.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a29f2e97df069d6a041094b4d306cffd522033ac
--- /dev/null
+++ b/list/taxonomy/anticoagulation_monitoring/flows/reassure_anticoag.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_anticoag
+type: resolution
+domain: anticoagulation_monitoring
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: anticoag_reassure
+      goal: "Acknowledge the patient's anticoagulation concern, note that their care team will be informed for routine follow-up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/anticoagulation_monitoring/flows/screen_anticoag.yaml b/list/taxonomy/anticoagulation_monitoring/flows/screen_anticoag.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..fbb96c3ce192ce049c00e9b8c27342f67a299242
--- /dev/null
+++ b/list/taxonomy/anticoagulation_monitoring/flows/screen_anticoag.yaml
@@ -0,0 +1,69 @@
+flow_id: screen_anticoag
+type: screening
+domain: anticoagulation_monitoring
+
+required_slots:
+  - bleeding_signs
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: anticoag_screen_step1
+      goal: "Assess last INR result and current bleeding signs"
+      tone: calm_urgent
+      must_include:
+        - "blood thinner"
+      must_ask:
+        - "Do you know your most recent INR result?"
+        - "Are you having any bleeding that is hard to stop, or blood in your stool or urine?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - last_inr_result
+      - bleeding_signs
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: anticoag_screen_step2
+      goal: "Check for new medications and dietary changes that affect anticoagulation"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "Have you started any new medications, vitamins, or supplements recently?"
+        - "Have there been any major changes in your diet, especially green leafy vegetables?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - new_medications
+      - dietary_changes
+
+  - step: 3
+    type: ask
+    response_spec:
+      id: anticoag_screen_step3
+      goal: "Assess bruising severity"
+      tone: calm_urgent
+      must_include:
+        - "understand"
+      must_ask:
+        - "Have you noticed any unusual bruising, or bruises that appear without injury?"
+      must_not:
+        - "don't worry"
+        - "diagnos"
+      max_questions: 1
+    collects:
+      - bruising_assessment
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_r2: escalate_anticoag
+  on_low_risk: reassure_anticoag
+  on_unclear: clarify_anticoag
diff --git a/list/taxonomy/anticoagulation_monitoring/rules.yaml b/list/taxonomy/anticoagulation_monitoring/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ed960d3f49ff27263f7a49dde2db59663498c453
--- /dev/null
+++ b/list/taxonomy/anticoagulation_monitoring/rules.yaml
@@ -0,0 +1,33 @@
+domain: anticoagulation_monitoring
+target_risk_class: R2
+
+decision_rules:
+  - id: anticoagulation_monitoring_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: screen_anticoag
+
+  - id: anticoagulation_monitoring_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: screen_anticoag
+
+  - id: anticoagulation_monitoring_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify_anticoag
+
+  - id: anticoagulation_monitoring_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: anticoagulation_monitoring_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_anticoag
diff --git a/list/taxonomy/anticoagulation_monitoring/triggers.yaml b/list/taxonomy/anticoagulation_monitoring/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e58da322684e6f43e2bb864e206dd7aa2033ad10
--- /dev/null
+++ b/list/taxonomy/anticoagulation_monitoring/triggers.yaml
@@ -0,0 +1,94 @@
+domain: anticoagulation_monitoring
+priority: 77
+
+lexical_signals:
+  high:
+    phrases:
+      - "INR is high and I'm bleeding"
+      - "blood thinner and I can't stop bleeding"
+      - "warfarin and blood in my stool"
+      - "coumadin and I'm bruising badly"
+      - "blood thinner and blood in my urine"
+      - "INR above 4"
+      - "INR was 5"
+      - "nosebleed that won't stop on blood thinners"
+      - "coughing up blood on warfarin"
+      - "bleeding gums won't stop"
+      - "blood in stool on anticoagulant"
+      - "massive bruise on blood thinner"
+      - "INR is way too high"
+      - "blood thinner and I cut myself and it won't stop"
+      - "protime is elevated and I'm bleeding"
+    regex:
+      - "(?:INR|blood thinner|warfarin|coumadin).{0,20}(?:bleed|bruise|blood in)"
+      - "(?:INR|protime).{0,15}(?:high|above|over|\\d)"
+      - "(?:bleed|blood).{0,15}(?:won't stop|can't stop|doesn't stop).{0,15}(?:blood thinner|warfarin|coumadin)"
+      - "(?:blood in).{0,10}(?:stool|urine|spit|vomit).{0,15}(?:warfarin|coumadin|blood thinner|anticoag)"
+      - "(?:warfarin|coumadin|blood thinner|anticoag).{0,20}(?:blood in).{0,10}(?:stool|urine|spit|vomit)"
+  medium:
+    phrases:
+      - "concerned about my warfarin"
+      - "worried about my blood thinner"
+      - "bruising easily on coumadin"
+      - "lots of bruises"
+      - "bleeding more than usual"
+      - "coumadin question"
+      - "blood thinner concern"
+      - "INR question"
+      - "easy bruising on blood thinner"
+      - "small cuts bleed more"
+      - "gums bleed when I brush"
+      - "bruises appearing without reason"
+      - "worried about bleeding risk"
+      - "nosebleeds more frequent"
+    regex:
+      - "(?:warfarin|coumadin|blood thinner).{0,15}(?:concern|worry|question|afraid)"
+      - "(?:bruise|bleed).{0,15}(?:easy|won't stop|lots|more|frequent)"
+      - "(?:gum|nose|cut).{0,15}(?:bleed|blood).{0,15}(?:more|easy|won't stop|frequent)"
+      - "(?:bruise|bleed).{0,15}(?:without|no).{0,10}(?:reason|cause|injury)"
+  low:
+    partials:
+      - "blood thinner follow-up"
+      - "blood thinner check"
+      - "blood thinner lab"
+      - "INR test"
+      - "INR lab"
+      - "INR due"
+      - "warfarin"
+      - "coumadin"
+      - "blood thinner"
+      - "anticoagulant"
+      - "protime"
+
+negation_handling:
+  patterns:
+    - "INR is in range"
+    - "blood thinner working well"
+    - "no bleeding"
+    - "no bruising"
+    - "INR is stable"
+    - "warfarin dose is fine"
+    - "blood thinner is well controlled"
+    - "no issues with blood thinner"
+    - "INR results are normal"
+    - "no bleeding concerns"
+    - "bruising has improved"
+    # --- administrative context ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+    - "warfarin refill"
+    - "INR lab appointment"
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_on_medication_class: ["anticoagulants"]
+      reason: "Patient on anticoagulants with bleeding or INR concern signals"
+  boost_to_medium:
+    - when:
+        patient_on_medication: ["warfarin", "coumadin"]
+      reason: "Warfarin patient raises baseline concern for anticoagulation issues"
diff --git a/list/taxonomy/asthma_exacerbation/flows/clarify_asthma.yaml b/list/taxonomy/asthma_exacerbation/flows/clarify_asthma.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9876743ee3740c5b588284b8d662f1282633831a
--- /dev/null
+++ b/list/taxonomy/asthma_exacerbation/flows/clarify_asthma.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify_asthma
+type: clarification
+domain: asthma_exacerbation
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: asthma_exacerbation_clarify
+      goal: "Ask patient to describe their asthma symptoms more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - asthma_exacerbation_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/asthma_exacerbation/flows/escalate_asthma.yaml b/list/taxonomy/asthma_exacerbation/flows/escalate_asthma.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9f05d28630d0098c4f67d3044a22f4dc476f9969
--- /dev/null
+++ b/list/taxonomy/asthma_exacerbation/flows/escalate_asthma.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_asthma
+type: escalation
+domain: asthma_exacerbation
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: asthma_r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their asthma symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: asthma_r2_handoff
+      goal: "Schedule same-day nurse callback with asthma exacerbation context"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/asthma_exacerbation/flows/escalate_r2.yaml b/list/taxonomy/asthma_exacerbation/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f09021503d36fdf223b07a4a11b93c26755ff980
--- /dev/null
+++ b/list/taxonomy/asthma_exacerbation/flows/escalate_r2.yaml
@@ -0,0 +1,24 @@
+flow_id: escalate_r2
+type: escalation
+domain: asthma_exacerbation
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient about urgency of their asthma symptoms and transfer to a clinical team member for same-day evaluation"
+      tone: calm_direct
+      must_include:
+        - "nurse"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably nothing"
+        - "wait and see"
+      max_questions: 0
+
+exit:
+  on_complete: handoff
diff --git a/list/taxonomy/asthma_exacerbation/flows/handoff.yaml b/list/taxonomy/asthma_exacerbation/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f48649d117bd35789ad5c1fbbfa7ffb357086100
--- /dev/null
+++ b/list/taxonomy/asthma_exacerbation/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: asthma_exacerbation
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: asthma_exacerbation_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: asthma_exacerbation_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/asthma_exacerbation/flows/reassure_asthma.yaml b/list/taxonomy/asthma_exacerbation/flows/reassure_asthma.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b2688b68ec65e3ae1e690f96acf23ac7b253fc1b
--- /dev/null
+++ b/list/taxonomy/asthma_exacerbation/flows/reassure_asthma.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_asthma
+type: resolution
+domain: asthma_exacerbation
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: asthma_reassure
+      goal: "Acknowledge the patient's asthma concern, reinforce action plan adherence, note care team will be informed"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/asthma_exacerbation/flows/screen_asthma_status.yaml b/list/taxonomy/asthma_exacerbation/flows/screen_asthma_status.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1a4471c49e26aa7ddb405782517a891cdda6b48a
--- /dev/null
+++ b/list/taxonomy/asthma_exacerbation/flows/screen_asthma_status.yaml
@@ -0,0 +1,68 @@
+flow_id: screen_asthma_status
+type: screening
+domain: asthma_exacerbation
+
+required_slots:
+  - rescue_inhaler_use
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: asthma_screen_step1
+      goal: "Assess rescue inhaler frequency and peak flow reading"
+      tone: calm_urgent
+      must_include:
+        - "asthma"
+      must_ask:
+        - "How often have you been using your rescue inhaler in the last 24 hours?"
+        - "Have you checked your peak flow? What was the reading?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - rescue_inhaler_use
+      - peak_flow_reading
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: asthma_screen_step2
+      goal: "Assess nighttime symptoms and identify triggers"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "Have your asthma symptoms been waking you up at night?"
+        - "Have you been exposed to any known triggers recently?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - nighttime_symptoms
+      - trigger_exposure
+
+  - step: 3
+    type: ask
+    response_spec:
+      id: asthma_screen_step3
+      goal: "Determine action plan zone status"
+      tone: calm_urgent
+      must_include:
+        - "understand"
+      must_ask:
+        - "Based on your action plan, which zone would you say you are in - green, yellow, or red?"
+      must_not:
+        - "don't worry"
+        - "diagnos"
+      max_questions: 1
+    collects:
+      - action_plan_zone
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_asthma
+  on_low_risk: reassure_asthma
+  on_unclear: clarify_asthma
diff --git a/list/taxonomy/asthma_exacerbation/rules.yaml b/list/taxonomy/asthma_exacerbation/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e659d18cffe313fe06030bf9a0fdc02ddaa30a1e
--- /dev/null
+++ b/list/taxonomy/asthma_exacerbation/rules.yaml
@@ -0,0 +1,27 @@
+domain: asthma_exacerbation
+target_risk_class: R2
+
+decision_rules:
+  - id: asthma_exacerbation_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: screen_asthma_status
+
+  - id: asthma_exacerbation_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: screen_asthma_status
+
+  - id: asthma_exacerbation_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify_asthma
+
+  - id: asthma_exacerbation_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_asthma
diff --git a/list/taxonomy/asthma_exacerbation/triggers.yaml b/list/taxonomy/asthma_exacerbation/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..bb02e239fb0d5ad8bcf98ceb28949dd4b8cff569
--- /dev/null
+++ b/list/taxonomy/asthma_exacerbation/triggers.yaml
@@ -0,0 +1,92 @@
+domain: asthma_exacerbation
+priority: 76
+
+lexical_signals:
+  high:
+    phrases:
+      - "asthma attack"
+      - "asthma is really bad"
+      - "asthma flare-up"
+      - "inhaler is not helping"
+      - "rescue inhaler every hour"
+      - "albuterol every few hours"
+      - "can't stop wheezing"
+      - "asthma is out of control"
+      - "worst asthma in a long time"
+      - "asthma acting up badly"
+      - "rescue inhaler doesn't seem to work"
+      - "nebulizer every couple hours"
+      - "asthma emergency"
+      - "wheezing won't stop"
+      - "asthma is the worst it's been"
+    regex:
+      - "(?:asthma).{0,20}(?:attack|flare|worse|bad|out of control|emergency|act)"
+      - "(?:inhaler|albuterol|rescue).{0,15}(?:not.{0,10}help|doesn't|every.{0,10}(?:hour|few|couple))"
+      - "(?:can't|cannot).{0,10}(?:stop).{0,10}(?:wheez|cough)"
+      - "(?:wheez|cough).{0,10}(?:won't|doesn't|not).{0,10}(?:stop|go away)"
+  medium:
+    phrases:
+      - "wheezing is getting worse"
+      - "more wheezing at night"
+      - "chest is tight from asthma"
+      - "using inhaler more often"
+      - "coughing more at night"
+      - "asthma symptoms increasing"
+      - "breathing is tighter"
+      - "asthma is bothering me more"
+      - "peak flow is down"
+      - "in the yellow zone"
+      - "waking up wheezing"
+      - "can't exercise without wheezing"
+      - "cough keeps waking me up"
+      - "asthma has been acting up"
+      # --- MINIMIZER coverage ---
+      - "asthma is just a little worse"
+      - "maybe using my inhaler a bit more"
+      - "slight wheeze nothing major"
+    regex:
+      - "wheez.{0,20}(?:worse|increase|night|can't stop|more)"
+      - "(?:chest|breath).{0,15}tight.{0,15}asthma"
+      - "(?:peak flow|pef).{0,15}(?:down|low|drop|decrease)"
+      - "(?:yellow|red).{0,10}zone"
+      - "(?:cough|wheez).{0,15}(?:night|morning|wake|sleep)"
+      - "(?:just|only).{0,10}(?:a\\s+)?(?:little|bit).{0,10}(?:worse|more).{0,10}(?:asthma|wheez|cough)"
+  low:
+    partials:
+      - "cough at night"
+      - "wheeze in the morning"
+      - "asthma"
+      - "inhaler"
+      - "peak flow"
+      - "wheezing"
+      - "albuterol"
+      - "nebulizer"
+      - "asthma action plan"
+
+negation_handling:
+  patterns:
+    - "asthma is controlled"
+    - "no wheezing"
+    - "asthma is fine"
+    - "breathing is clear"
+    - "peak flow is normal"
+    - "in the green zone"
+    - "inhaler use is normal"
+    - "asthma is stable"
+    - "no asthma symptoms"
+    - "wheezing stopped"
+    - "asthma well controlled"
+    # --- administrative context ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+    - "inhaler refill"
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_has_condition: ["J45.*"]
+      reason: "Known asthma patient with exacerbation signals"
diff --git a/list/taxonomy/audit_c_positive/flows/audit_c_screen.yaml b/list/taxonomy/audit_c_positive/flows/audit_c_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..746811d05294e75fc5071a03dd3af5e1511749c5
--- /dev/null
+++ b/list/taxonomy/audit_c_positive/flows/audit_c_screen.yaml
@@ -0,0 +1,55 @@
+flow_id: audit_c_screen
+type: screening
+domain: audit_c_positive
+
+required_slots:
+  - alcohol_frequency
+  - alcohol_quantity
+  - alcohol_binge_frequency
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: audit_c_screen_step1
+      goal: "Ask about frequency of alcohol use in a conversational, non-judgmental way"
+      tone: warm_professional
+      must_include:
+        - "alcohol"
+      must_ask:
+        - "How often do you have a drink containing alcohol?"
+      must_not:
+        - "AUDIT"
+        - "screening tool"
+        - "alcoholic"
+        - "problem"
+      max_questions: 1
+    collects:
+      - alcohol_frequency
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: audit_c_screen_step2
+      goal: "Ask about typical quantity per drinking occasion and binge frequency"
+      tone: warm_professional
+      must_include:
+        - "drinks"
+      must_ask:
+        - "On a typical day when you do drink, how many drinks do you have?"
+        - "How often do you have six or more drinks on one occasion?"
+      must_not:
+        - "AUDIT"
+        - "score"
+        - "problem drinker"
+        - "alcoholic"
+      max_questions: 2
+    collects:
+      - alcohol_quantity
+      - alcohol_binge_frequency
+
+exit:
+  on_complete: evaluate_concern
+  on_concern: brief_intervention_referral
+  on_low_risk: brief_intervention_referral
+  on_unclear: brief_intervention_referral
diff --git a/list/taxonomy/audit_c_positive/flows/brief_intervention_referral.yaml b/list/taxonomy/audit_c_positive/flows/brief_intervention_referral.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ea4808943b5be93ce8d6a3a7c44196b92b473ded
--- /dev/null
+++ b/list/taxonomy/audit_c_positive/flows/brief_intervention_referral.yaml
@@ -0,0 +1,25 @@
+flow_id: brief_intervention_referral
+type: resolution
+domain: audit_c_positive
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: audit_c_brief_intervention
+      goal: "Thank the patient for sharing and inform them their care team will have this information. Do NOT reveal any score or clinical interpretation."
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "thank you for sharing"
+      must_not:
+        - "score"
+        - "AUDIT"
+        - "alcoholic"
+        - "problem"
+        - "elevated"
+        - "positive"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/audit_c_positive/flows/clarify.yaml b/list/taxonomy/audit_c_positive/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a3bc161b4055bd718ed7ca57d16f2d915da71a5f
--- /dev/null
+++ b/list/taxonomy/audit_c_positive/flows/clarify.yaml
@@ -0,0 +1,26 @@
+flow_id: clarify
+type: clarification
+domain: audit_c_positive
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: audit_c_clarify
+      goal: "Ask the patient to tell more about their drinking habits in a non-judgmental way"
+      tone: warm_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "alcoholic"
+        - "problem"
+        - "AUDIT"
+      max_questions: 1
+    collects:
+      - audit_c_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/audit_c_positive/rules.yaml b/list/taxonomy/audit_c_positive/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..29f1b209014db88790b00eba4ee39a109420e0aa
--- /dev/null
+++ b/list/taxonomy/audit_c_positive/rules.yaml
@@ -0,0 +1,27 @@
+domain: audit_c_positive
+target_risk_class: R1
+
+decision_rules:
+  - id: audit_c_positive_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: audit_c_screen
+
+  - id: audit_c_positive_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: audit_c_screen
+
+  - id: audit_c_positive_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: audit_c_positive_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: brief_intervention_referral
diff --git a/list/taxonomy/audit_c_positive/triggers.yaml b/list/taxonomy/audit_c_positive/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d58c81ee03c5192a59dbad56dc6aacf52a24d523
--- /dev/null
+++ b/list/taxonomy/audit_c_positive/triggers.yaml
@@ -0,0 +1,77 @@
+domain: audit_c_positive
+priority: 36
+
+lexical_signals:
+  high:
+    phrases:
+      - "drinking every day now"
+      - "several drinks a day"
+      - "can't stop drinking"
+      - "drinking more than I should"
+      - "drink a bottle of wine every night"
+      - "six or more drinks at a time"
+      - "binge drinking on weekends"
+      - "drinking has gotten out of control"
+      - "need a drink to get through the day"
+      - "finish a bottle of liquor in a day"
+      - "drinking from morning to night"
+      - "a twelve pack a day"
+      - "heavy drinking every night"
+      - "drink until I pass out"
+      - "blackout from drinking"
+      - "can't remember what happened after drinking"
+    regex:
+      - "(drink|drinking).{0,15}(every\\s+day|daily|all\\s+day|morning|constantly|heavily|more\\s+than)"
+      - "(several|multiple|many|six|seven|eight|nine|ten).{0,10}(drink|beer|glass|shot)s?.{0,10}(a\\s+day|daily|per\\s+day|each\\s+day)"
+      - "(can't|cannot)\\s+(stop|quit|control).{0,10}(drink|alcohol)"
+      - "(bottle|six\\s+pack|twelve\\s+pack|case).{0,10}(a\\s+day|every\\s+night|daily|each\\s+night)"
+      - "(binge|blackout|pass\\s+out).{0,10}(drink|drunk|alcohol)"
+  medium:
+    phrases:
+      - "drinking more lately"
+      - "a few drinks a day"
+      - "drink every day"
+      - "beer every night"
+      - "wine every evening"
+      - "more alcohol than usual"
+      - "having a couple drinks daily"
+      - "increased my drinking"
+      - "hard liquor most nights"
+      - "drinking has increased"
+      - "cocktails after work every day"
+      - "drink more than I used to"
+      - "a drink or two every night"
+    regex:
+      - "(drink|drinking).{0,15}(more|increased|lately|recently|too\\s+much)"
+      - "(beer|wine|liquor|alcohol|cocktail).{0,15}(every|each|most)\\s+(night|evening|day)"
+      - "(a\\s+few|couple|two|three).{0,10}(drink|beer|glass|shot)s?.{0,10}(a\\s+day|daily|every)"
+  low:
+    partials:
+      - "beer"
+      - "wine"
+      - "liquor"
+      - "drinking"
+      - "alcohol"
+      - "cocktail"
+
+negation_handling:
+  patterns:
+    - "don't drink"
+    - "not drinking"
+    - "stopped drinking"
+    - "quit drinking"
+    - "sober"
+    - "no alcohol"
+    - "don't drink alcohol"
+    - "gave up drinking"
+    - "haven't had a drink"
+    - "teetotaler"
+    - "don't touch alcohol"
+    - "cut back on drinking"
+    - "rarely drink"
+    - "only socially"
+    - "just one on occasion"
+    - "not much of a drinker"
+    - "never been a drinker"
+    - "alcohol free"
+  action: downgrade_confidence
diff --git a/list/taxonomy/behavioral_crisis/flows/clarify.yaml b/list/taxonomy/behavioral_crisis/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..960b11a94424ebd22728e6842894a1524f968850
--- /dev/null
+++ b/list/taxonomy/behavioral_crisis/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: behavioral_crisis
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: behavioral_crisis_clarify
+      goal: "Ask patient to describe their behavioral crisis symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - behavioral_crisis_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/behavioral_crisis/flows/escalate_r2.yaml b/list/taxonomy/behavioral_crisis/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0a5657f0393a59f71ae85e9ec676fadb11ea230c
--- /dev/null
+++ b/list/taxonomy/behavioral_crisis/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: behavioral_crisis
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/behavioral_crisis/flows/escalate_r3.yaml b/list/taxonomy/behavioral_crisis/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..00271cb296870cf74f42c2815e66163f7015fe6c
--- /dev/null
+++ b/list/taxonomy/behavioral_crisis/flows/escalate_r3.yaml
@@ -0,0 +1,26 @@
+flow_id: escalate_r3
+type: escalation
+domain: behavioral_crisis
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: behavioral_r3_escalation_notice
+    goal: Instruct patient or caller to call 911 for behavioral crisis with immediate
+      safety risk
+    tone: calm_urgent
+    must_include:
+    - call 911
+    - emergency
+    - safety
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - calm down
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+exit:
+  on_complete: end
diff --git a/list/taxonomy/behavioral_crisis/flows/handoff.yaml b/list/taxonomy/behavioral_crisis/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c679104b301b46147e22a5a350a568915b59fb5c
--- /dev/null
+++ b/list/taxonomy/behavioral_crisis/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: behavioral_crisis
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: behavioral_crisis_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: behavioral_crisis_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/behavioral_crisis/flows/safety_screen.yaml b/list/taxonomy/behavioral_crisis/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c10a92992e0ec400170328474f05debc55cc9589
--- /dev/null
+++ b/list/taxonomy/behavioral_crisis/flows/safety_screen.yaml
@@ -0,0 +1,54 @@
+flow_id: safety_screen
+type: screening
+domain: behavioral_crisis
+
+required_slots:
+  - behavior_description
+  - safety_risk
+  - triggers_identified
+  - support_available
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "behavior description"
+        - "safety risk"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - behavior_description
+      - safety_risk
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "triggers identified"
+        - "support available"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - triggers_identified
+      - support_available
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/list/taxonomy/behavioral_crisis/rules.yaml b/list/taxonomy/behavioral_crisis/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..2fb81382d046a49a6ffa66955cd97a89d5bd3238
--- /dev/null
+++ b/list/taxonomy/behavioral_crisis/rules.yaml
@@ -0,0 +1,33 @@
+domain: behavioral_crisis
+target_risk_class: R2
+
+decision_rules:
+  - id: behavioral_crisis_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: behavioral_crisis_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: behavioral_crisis_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: behavioral_crisis_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: behavioral_crisis_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/behavioral_crisis/triggers.yaml b/list/taxonomy/behavioral_crisis/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e81c63674ca59068d954bcc4bc50c8219f4882a1
--- /dev/null
+++ b/list/taxonomy/behavioral_crisis/triggers.yaml
@@ -0,0 +1,239 @@
+domain: behavioral_crisis
+priority: 63
+
+lexical_signals:
+  high:
+    phrases:
+      # --- original ---
+      - "completely out of control"
+      - "behavioral crisis"
+      - "agitated and won't calm down"
+      - "breaking things and screaming"
+      - "aggressive and scared"
+      - "psychiatric emergency"
+      # --- expanded naturalistic ---
+      - "acting violent"
+      - "threatening to hurt someone"
+      - "destroying things"
+      - "screaming and won't stop"
+      - "having a complete breakdown"
+      - "psychotic episode"
+      - "seeing things that aren't there"
+      - "hearing voices telling him to hurt people"
+      - "hearing voices telling her to hurt people"
+      - "agitated and aggressive"
+      - "combative and out of control"
+      - "tried to attack someone"
+      - "throwing things at people"
+      - "violent and uncontrollable"
+      - "threatening to harm himself"
+      - "threatening to harm herself"
+      - "danger to self or others"
+      - "in a full psychotic state"
+      - "hallucinating and violent"
+      - "manic and aggressive"
+    regex:
+      # --- original ---
+      - "behavioral\\s+crisis"
+      - "(psychiatric|mental\\s+health)\\s+emergency"
+      # --- expanded ---
+      - "(acting|becoming|getting|turned)\\s+(violent|aggressive|combative|hostile)"
+      - "threaten(ing|ed|s)?\\s+(to\\s+)?(hurt|harm|kill|attack|hit)"
+      - "(destroy|breaking|smashing|throwing)\\s+(things|furniture|objects|stuff)"
+      - "(screaming|yelling|shouting)\\s+(and\\s+)?(won'?t|can'?t|not)\\s+(stop|calm)"
+      - "(complete|total|full|mental)\\s+(breakdown|meltdown|psychotic)"
+      - "(psychotic|psychosis)\\s+(episode|break|state)"
+      - "(seeing|hearing)\\s+(things|voices|people)\\s+(that|who|which)\\s+(aren'?t|are\\s+not|don'?t)"
+      - "hearing\\s+voices\\s+(telling|commanding|saying|ordering)"
+      - "(agitated|aggressive|combative)\\s+(and\\s+)?(out\\s+of\\s+control|uncontrollable|violent|dangerous)"
+      - "danger(ous)?\\s+(to\\s+)?(self|himself|herself|others|people)"
+      - "(hallucinating|delusional)\\s+(and\\s+)?(violent|aggressive|dangerous|combative)"
+      - "(manic|frenzied)\\s+(and\\s+)?(aggressive|violent|out\\s+of\\s+control)"
+  medium:
+    phrases:
+      # --- original ---
+      - "very agitated"
+      - "can't calm down"
+      - "extremely anxious and acting out"
+      - "emotional crisis"
+      - "behavioral episode"
+      - "severe agitation"
+      # --- expanded naturalistic ---
+      - "extremely anxious"
+      - "having a panic attack"
+      - "confused and aggressive"
+      - "pacing and yelling"
+      - "refusing to cooperate"
+      - "not making any sense"
+      - "talking to people who aren't there"
+      - "very paranoid"
+      - "very disoriented and upset"
+      - "won't let anyone near"
+      - "becoming increasingly agitated"
+      - "getting more and more worked up"
+      - "lashing out at staff"
+      - "lashing out at family"
+      - "screaming at everyone"
+      - "very confused and combative"
+      - "pulling out their IV"
+      - "trying to leave against medical advice"
+      - "threatening to leave AMA"
+      - "cannot be redirected"
+      - "escalating behavior"
+      - "delusional and frightened"
+      - "paranoid and hiding"
+      - "extremely irritable and aggressive"
+      - "swinging at people"
+      - "cursing and throwing things"
+      - "erratic and unpredictable behavior"
+      - "sundowning and aggressive"
+      - "severely anxious and inconsolable"
+      # --- MINIMIZER coverage ---
+      - "he's just being difficult"
+      - "she gets like this sometimes"
+      - "it's not that bad, just a tantrum"
+      - "just a bit worked up"
+      - "acting out a little"
+      - "being a bit aggressive but nothing too bad"
+      - "just having a bad day"
+      - "a little agitated but I can handle it"
+      - "things got a bit heated"
+      # --- Caregiver downplaying patterns (R2 recall) ---
+      - "shouldn't be calling about this"
+      - "probably shouldn't be calling"
+      - "maybe I'm overreacting"
+      - "gets like this"
+      - "he gets like this"
+      - "she gets like this"
+      # --- Property damage patterns ---
+      - "broke something"
+      - "broke a hole in the wall"
+      - "threw things"
+      - "throwing things"
+      - "punched the wall"
+      - "punched a hole"
+      - "kicked the door"
+      - "smashed something"
+      - "damaged property"
+      # --- escalation / deterioration ---
+      - "getting worse by the minute"
+      - "behavior is escalating"
+      - "situation is deteriorating"
+      - "medications not helping"
+      - "can't redirect"
+      - "tried everything"
+      - "heading for the door"
+      - "hitting himself"
+      - "hitting herself"
+      - "banging head"
+      - "threw a plate"
+      - "smashed a glass"
+      # --- Phase 6: R2 recall expansion ---
+      - "behavior is escalating"
+      - "situation is deteriorating"
+      - "can't redirect"
+      - "tried everything"
+      - "hitting himself"
+      - "banging head"
+    regex:
+      - "(very|extremely|severely|increasingly)\\s+(agitated|anxious|paranoid|confused|irritable|upset)"
+      - "(can'?t|won'?t|unable\\s+to|not\\s+able\\s+to)\\s+(calm|settle|relax|cooperate|be\\s+redirected)"
+      - "(pacing|rocking|screaming|yelling|cursing)\\s+(and\\s+)?(yelling|screaming|won'?t|refusing)"
+      - "talking\\s+to\\s+(people|someone|things)\\s+(who|that)\\s+(aren'?t|are\\s+not|don'?t)"
+      - "(refusing|won'?t|will\\s+not)\\s+(cooperate|comply|listen|take|let)"
+      - "(confused|disoriented)\\s+(and\\s+)?(aggressive|combative|agitated|violent|upset)"
+      - "(pulling|ripping|yanking)\\s+(out|off)\\s+(IV|lines|tubes|monitor)"
+      - "(lashing|striking|swinging|hitting)\\s+(out\\s+)?(at\\s+)?(staff|nurse|family|people|everyone)"
+      - "(escalating|worsening|increasing)\\s+(behavior|agitation|aggression)"
+      - "(erratic|unpredictable|bizarre|irrational)\\s+(behavior|actions|conduct)"
+      - "sundowning\\s+(and\\s+)?(agitat|aggress|combative|confused)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(just|only).{0,10}(a\\s+)?(little|bit|being).{0,10}(difficult|worked up|agitated|aggressive|upset|angry|violent)"
+      - "(gets?\\s+like\\s+this|always\\s+does\\s+this|does\\s+this\\s+sometimes).{0,15}(it's|not|nothing)"
+      - "(not\\s+that\\s+bad|nothing\\s+too|can\\s+handle|I\\s+can\\s+manage).{0,20}(agitat|aggress|upset|angry|violent|tantrum)"
+      - "(things|it|situation).{0,10}(got|getting|a\\s+bit).{0,10}(heated|out of hand|intense|scary|worse|wild)"
+      # --- destructive acts ---
+      - "(threw|throwing|smashing|breaking)\\s+(a\\s+)?(plate|glass|chair|phone|things)"
+      # --- safety concern for others ---
+      - "(scared|worried|afraid)\\s+(for|about)\\s+(the\\s+)?(staff|other|family|patients|safety)"
+      # --- Phase 6: R2 recall expansion ---
+      - "(behavior|situation).{0,20}(escalating|deteriorating|getting worse|out of control)"
+      - "(can't|cannot|unable to).{0,15}(redirect|calm|control|manage).{0,10}(him|her|them)"
+      - "(hitting|banging|hurting).{0,15}(himself|herself|head|wall|self)"
+      - "(scared|worried|afraid).{0,20}(for|about).{0,15}(safety|staff|others|family)"
+    partials:
+      - "agitation"
+      - "combative behavior"
+      - "behavioral escalation"
+      - "paranoid behavior"
+      - "panic attack"
+      - "acute confusion with aggression"
+      - "delirium with agitation"
+  low:
+    partials:
+      # --- original ---
+      - "agitated"
+      - "behavioral issue"
+      - "crisis"
+      - "acting out"
+      # --- expanded ---
+      - "psychosis"
+      - "mania"
+      - "agitation"
+      - "delirium"
+      - "acute behavioral change"
+      - "behavioral emergency"
+      - "acute psychosis"
+      - "acute mania"
+      - "altered mental status"
+      - "psychiatric crisis"
+      - "combative"
+      - "violent behavior"
+      - "behavioral disturbance"
+      - "seclusion needed"
+      - "restraint"
+      - "involuntary hold"
+      - "danger to self"
+      - "danger to others"
+      - "5150 hold"
+
+negation_handling:
+  patterns:
+    # --- original ---
+    - "calmed down"
+    - "behavior improved"
+    - "no behavioral issues"
+    # --- expanded ---
+    - "panic attack resolved"
+    - "feeling better now"
+    - "settled down"
+    - "agitation improving"
+    - "calmer after medication"
+    - "responding to redirection"
+    - "no longer aggressive"
+    - "behavior returning to baseline"
+    - "de-escalated successfully"
+    - "patient cooperative now"
+    - "no current safety concerns"
+    - "no violent behavior"
+    - "anxiety improving"
+    - "resting comfortably now"
+    - "calm and oriented"
+    - "no psychiatric emergency"
+    - "behavioral episode has passed"
+    - "medication helped calm them down"
+    - "able to be redirected now"
+    - "no agitation at this time"
+    - "pleasant and cooperative"
+    - "mood has stabilized"
+    - "hallucinations resolved with medication"
+    - "no longer hearing voices"
+    - "paranoia has improved"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
diff --git a/list/taxonomy/caregiver_safety_concern/flows/clarify.yaml b/list/taxonomy/caregiver_safety_concern/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4a2c640933f6abea8636ca2f5f8e57b50237da70
--- /dev/null
+++ b/list/taxonomy/caregiver_safety_concern/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: caregiver_safety_concern
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: caregiver_safety_concern_clarify
+      goal: "Ask patient to describe their caregiver safety concern symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - caregiver_safety_concern_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/caregiver_safety_concern/flows/escalate_r1.yaml b/list/taxonomy/caregiver_safety_concern/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e25e71313c6a7b13df03ab96615f1899c2ff959f
--- /dev/null
+++ b/list/taxonomy/caregiver_safety_concern/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: caregiver_safety_concern
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/caregiver_safety_concern/flows/handoff.yaml b/list/taxonomy/caregiver_safety_concern/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ebd33faad874a47c7a87bcd3ef11067e0f265850
--- /dev/null
+++ b/list/taxonomy/caregiver_safety_concern/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: caregiver_safety_concern
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: caregiver_safety_concern_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: caregiver_safety_concern_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/caregiver_safety_concern/rules.yaml b/list/taxonomy/caregiver_safety_concern/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7a8db4a3e68674f8889f70b6f9130b5d9450afd8
--- /dev/null
+++ b/list/taxonomy/caregiver_safety_concern/rules.yaml
@@ -0,0 +1,21 @@
+domain: caregiver_safety_concern
+target_risk_class: R1
+
+decision_rules:
+  - id: caregiver_safety_concern_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r1
+
+  - id: caregiver_safety_concern_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r1
+
+  - id: caregiver_safety_concern_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/caregiver_safety_concern/triggers.yaml b/list/taxonomy/caregiver_safety_concern/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1790acdc2193d2d06032fe4a74574d89a69ae922
--- /dev/null
+++ b/list/taxonomy/caregiver_safety_concern/triggers.yaml
@@ -0,0 +1,51 @@
+domain: caregiver_safety_concern
+priority: 47
+
+lexical_signals:
+  high:
+    phrases:
+      - "worried about patient safety at home"
+      - "don't think they're safe alone"
+      - "caregiver concerned about safety"
+      - "not safe to be home alone"
+      - "afraid they'll fall or get hurt at home"
+      - "patient is unsafe at home"
+      - "can't leave them alone"
+      - "they keep falling at home"
+      - "I'm scared something will happen"
+      - "not capable of caring for themselves"
+      - "the home isn't safe for them"
+      - "I don't think they can manage alone"
+      - "worried they'll hurt themselves"
+    regex:
+      - "(worried|concerned|afraid|scared).*(safe|safety|fall|hurt)\\s*(at\\s+)?home"
+      - "(not|isn'?t|can'?t)\\s+(safe|manage|care).*home"
+      - "(can'?t|shouldn'?t)\\s+(leave|be left)\\s+(them|him|her)\\s+alone"
+      - "not\\s+(capable|able)\\s+.*\\s+(care|manage|alone)"
+  medium:
+    phrases:
+      - "concerned about their ability at home"
+      - "they seem unsafe on their own"
+      - "worried about them being alone"
+      - "caregiver has concerns about safety"
+      - "don't feel comfortable leaving them alone"
+      - "struggling to take care of them"
+      - "need more help at home"
+      - "overwhelmed as a caregiver"
+      - "they can't do things on their own"
+      - "not sure they're safe"
+      - "worried about leaving them"
+  low:
+    partials:
+      - "safety concern"
+      - "home safety"
+      - "unsafe at home"
+      - "caregiver worry"
+      - "can't manage alone"
+
+negation_handling:
+  patterns:
+    - "safe at home"
+    - "doing well at home"
+    - "no safety concerns"
+  action: downgrade_confidence
diff --git a/list/taxonomy/chest_pain/flows/clarify.yaml b/list/taxonomy/chest_pain/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..866e87b3762ad30cb0db8040a6bb0ed4173a3516
--- /dev/null
+++ b/list/taxonomy/chest_pain/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: chest_pain
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: chest_pain_clarify
+      goal: "Ask patient to describe their chest-related symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 2
+    collects:
+      - chest_pain_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/chest_pain/flows/escalate_r2.yaml b/list/taxonomy/chest_pain/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e7c90e9ee922d01fd777342696e811bafbf85655
--- /dev/null
+++ b/list/taxonomy/chest_pain/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: chest_pain
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up soon about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "emergency"
+        - "heart attack"
+        - "diagnos"
+        - "don't worry"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: soon
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/chest_pain/flows/escalate_r3.yaml b/list/taxonomy/chest_pain/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c04697565532b031cc0cb247f6a26ea36384e4b8
--- /dev/null
+++ b/list/taxonomy/chest_pain/flows/escalate_r3.yaml
@@ -0,0 +1,38 @@
+flow_id: escalate_r3
+type: escalation
+domain: chest_pain
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Inform patient this requires immediate clinical attention and they will
+      be transferred
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - heart attack
+    - don't worry
+    - diagnos
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/chest_pain/flows/handoff.yaml b/list/taxonomy/chest_pain/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7345f567137f66837a8c64d0c227ac0d48ebd4ff
--- /dev/null
+++ b/list/taxonomy/chest_pain/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: chest_pain
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: chest_pain_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: chest_pain_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/chest_pain/flows/reassure_low_risk.yaml b/list/taxonomy/chest_pain/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3b02c7612135047170c5a613ff05e62b905dd6ad
--- /dev/null
+++ b/list/taxonomy/chest_pain/flows/reassure_low_risk.yaml
@@ -0,0 +1,23 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: chest_pain
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: chest_pain_low_risk_reassure
+      goal: "Reassure patient with low-risk chest symptoms and provide guidance"
+      tone: warm_professional
+      must_include:
+        - "glad"
+        - "symptoms"
+      must_ask: []
+      must_not:
+        - "nothing wrong"
+        - "diagnos"
+        - "guarantee"
+      max_questions: 1
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/chest_pain/flows/safety_screen.yaml b/list/taxonomy/chest_pain/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9918409e3696222bd4e78a7f62f6b4292b76cdf0
--- /dev/null
+++ b/list/taxonomy/chest_pain/flows/safety_screen.yaml
@@ -0,0 +1,54 @@
+flow_id: safety_screen
+type: screening
+domain: chest_pain
+
+required_slots:
+  - chest_pain_onset
+  - chest_pain_severity
+  - shortness_of_breath
+  - syncope_or_dizziness
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_onset
+      goal: "Determine when chest pain started and its severity"
+      tone: calm_urgent
+      must_include:
+        - "when"
+        - "pain"
+      must_ask:
+        - "chest pain start"
+        - "how severe"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - chest_pain_onset
+      - chest_pain_severity
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_associated
+      goal: "Screen for associated dangerous symptoms"
+      tone: calm_urgent
+      must_include:
+        - "breathing"
+      must_ask:
+        - "shortness of breath"
+        - "dizzy or lightheaded"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - shortness_of_breath
+      - syncope_or_dizziness
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_unclear: escalate_r3
diff --git a/list/taxonomy/chest_pain/rules.yaml b/list/taxonomy/chest_pain/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..06b6ca61b263c86e9fe3a7dd4752068384efaff4
--- /dev/null
+++ b/list/taxonomy/chest_pain/rules.yaml
@@ -0,0 +1,35 @@
+domain: chest_pain
+target_risk_class: R3
+
+decision_rules:
+  # Confidence-based rules for initial triage (from nominations)
+  - id: chest_pain_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: chest_pain_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: chest_pain_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  # Risk-based rules (used after risk evaluation)
+  - id: chest_pain_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: chest_pain_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/chest_pain/triggers.yaml b/list/taxonomy/chest_pain/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f441702740bf907d02c711c590dec08bece6061b
--- /dev/null
+++ b/list/taxonomy/chest_pain/triggers.yaml
@@ -0,0 +1,287 @@
+domain: chest_pain
+priority: 100
+
+lexical_signals:
+  high:
+    phrases:
+      - "chest pain"
+      - "chest pressure"
+      - "chest tightness"
+      - "heart attack"
+      - "crushing pain in my chest"
+      - "chest hurts"
+      - "pain in my chest"
+      - "tightness in my chest"
+      - "pressure in my chest"
+      - "heavy feeling in my chest"
+      - "my chest is killing me"
+      - "sharp pain in my chest"
+      - "stabbing pain in my chest"
+      - "squeezing feeling in my chest"
+      - "burning in my chest"
+      - "chest feels like it is being crushed"
+      - "feels like someone is sitting on my chest"
+      - "woke up with chest pain"
+      - "chest pain won't go away"
+      - "severe chest pain"
+      - "horrible pain in my chest"
+      - "chest pain and shortness of breath"
+      - "chest pain going down my arm"
+      - "I think I am having a heart attack"
+      - "feels like my heart is being squeezed"
+    regex:
+      - "chest\\s+(pain|pressure|tight|heavy|hurt|squeez|crush)"
+      - "(pain|pressure|tight|heavy|hurt|squeez|crush|ache|discomfort).{0,25}(in\\s+)?(my\\s+)?chest"
+      - "chest.{0,25}(pain|pressure|tight|heavy|hurt|squeez|crush|ache)"
+      - "(someone|something).{0,20}(sitting|pressing|pushing).{0,20}(on\\s+)?(my\\s+)?chest"
+      - "chest.{0,15}(feels?|is).{0,10}(heavy|tight|weird|funny|off|strange|wrong|bad|awful)"
+      - "chest.{0,10}(is\\s+)?kill(ing|s)\\s+me"
+      - "(sharp|stabbing|burning|searing|tearing).{0,15}(pain|feeling).{0,15}(in\\s+)?(my\\s+)?chest"
+      - "chest.{0,15}(won[']?t|doesn[']?t|isn[']?t).{0,10}(go away|stop|let up|ease)"
+      - "(woke|wake).{0,10}up.{0,15}chest\\s+(pain|hurt|pressure|tight)"
+      - "having\\s+a\\s+heart\\s+attack"
+      - "think.{0,10}(heart\\s+attack|cardiac)"
+      - "chest.{0,10}(and|with).{0,10}(short|can[']?t\\s+breath|hard\\s+to\\s+breath)"
+      - "horrible.{0,10}(pain|feeling).{0,10}(in\\s+)?(my\\s+)?chest"
+      - "chest\\s+(thing|stuff|issue|problem).{0,15}(heavy|tight|squeez|crush|pressure|pain|hurt|ache|bad)"
+      - "(rub|clutch|grab|hold|grip)(b?ing|bed|s)?.{0,10}(his|her|my|the)?\\s*chest"
+      - "chest.{0,10}(rub|clutch|grab|hold|grip)"
+  medium:
+    phrases:
+      - "hurts when I breathe"
+      - "pain in my left arm"
+      - "pain radiating"
+      - "sweating and chest feels weird"
+      - "chest feels weird"
+      - "chest feels kind of tight"
+      - "chest feels kinda weird"
+      - "heart is racing and chest hurts"
+      - "feels like an elephant on my chest"
+      - "hurts right here in the middle of my chest"
+      - "got this ache in my chest"
+      - "my chest keeps hurting on and off"
+      - "every time I take a deep breath my chest hurts"
+      - "left side of my chest is aching"
+      - "woke up and my chest felt tight"
+      - "jaw hurts and I feel pressure in my chest"
+      - "arm went numb and my chest feels funny"
+      - "nauseous and my chest hurts"
+      - "sweating for no reason and my chest feels heavy"
+      - "short of breath and my chest is tight"
+      - "I got dizzy and then my chest started hurting"
+      - "it comes and goes but my chest keeps aching"
+      - "chest has been bothering me all day"
+      - "something does not feel right in my chest"
+      - "my heart feels like it is fluttering and my chest hurts"
+      - "dull ache in the center of my chest"
+      - "band around my chest"
+      - "feels like a band around my chest"
+      - "chest pain after walking up the stairs"
+      - "chest started hurting during exercise"
+      - "rubbing his chest"
+      - "rubbing her chest"
+      - "rubbing my chest"
+      - "holding his chest"
+      - "grabbing his chest"
+      - "clutching his chest"
+      - "chest feels kinda tight"
+    regex:
+      - "(left\\s+arm|jaw|shoulder).{0,20}(pain|numb|tingle|ache|hurt)"
+      - "(pain|ache|hurt).{0,20}(radiat|spread|shoot|going).{0,15}(arm|shoulder|jaw|back|neck)"
+      - "(sweat|nausea|diaphores).{0,30}chest"
+      - "chest.{0,30}(sweat|nausea|diaphores)"
+      - "(left\\s+side|center|middle).{0,15}(of\\s+)?(my\\s+)?chest.{0,15}(ach|hurt|pain|bother)"
+      - "chest.{0,15}(bother|nag|bug).{0,5}(ing|ed|s)\\s+me"
+      - "(deep\\s+breath|breath\\s+in|inhale).{0,20}(chest|hurt|pain|ache)"
+      - "chest.{0,10}(on\\s+and\\s+off|come.{0,5}and\\s+go)"
+      - "(dizzy|lightheaded|faint).{0,20}chest"
+      - "chest.{0,20}(dizzy|lightheaded|faint)"
+      - "(short\\s+of\\s+breath|breathless|can[']?t\\s+catch).{0,20}chest"
+      - "heart.{0,10}(flutter|skip|race|pound).{0,15}chest"
+      - "(band|belt|strap).{0,10}(around|across).{0,10}chest"
+      - "dull.{0,5}(ache|pain).{0,10}(in\\s+)?(my\\s+)?chest"
+      - "chest.{0,15}(start|began|begin).{0,15}(hurt|ach|bother)"
+      - "(walk|stair|exert|exercis|exertion).{0,20}chest\\s+(pain|hurt|tight|pressure)"
+      - "chest.{0,20}(walk|stair|exert|exercis)"
+      - "(nauseous|throwing\\s+up|vomit).{0,20}chest"
+      - "(arm|shoulder).{0,10}(went|go|is|feel).{0,5}(numb|tingle)"
+      - "(rub|clutch|grab|hold)(b?ing|bed|s)?.{0,15}(his|her|my|the)?\\s*chest"
+      - "(looks?|looking)\\s+(pale|gray|grey|ashen|sweaty|clammy).{0,30}chest"
+    partials:
+      - "sternum"
+      - "angina"
+  low:
+    phrases:
+      - "feels funny in my chest"
+      - "something is off in my chest"
+      - "my chest has been acting up"
+      - "got a twinge in my chest"
+      - "a little discomfort in my chest area"
+    partials:
+      - "angina"
+      - "chest discomfort"
+      - "twinge"
+      - "chest area"
+      - "heart area"
+      - "breastbone"
+      - "chest thing"
+      - "chest stuff"
+
+negation_handling:
+  patterns:
+    - "no chest pain"
+    - "not having chest pain"
+    - "don't have chest pain"
+    - "no pain in my chest"
+    - "chest is fine"
+    - "no chest problems"
+    - "chest pain resolved"
+    - "chest pain gone"
+    - "reproducible"
+    - "when i press"
+    - "when i push on"
+    - "when i twist"
+    - "when i stretch"
+    - "when i rotate"
+    - "worse with movement"
+    - "worse with certain movements"
+    - "positional"
+    - "localized ache"
+    - "comes and goes with"
+    - "costochondritis"
+    - "musculoskeletal"
+    - "no crushing"
+    - "not cardiac"
+    - "chest pain is gone now"
+    - "chest pain went away"
+    - "chest does not hurt anymore"
+    - "chest feels fine now"
+    - "no tightness"
+    - "no pressure in my chest"
+    - "chest pain only when I press on it"
+    - "hurts only when I move a certain way"
+    - "pain goes away when I rest"
+    - "just heartburn"
+    - "it was just gas"
+    - "doctor said it was muscular"
+    - "already evaluated for chest pain"
+    - "stress related"
+    - "anxiety chest tightness"
+    - "panic attack"
+    - "when i poke"
+    - "only when i press"
+    - "only with movement"
+    - "tender to touch"
+    - "sore to touch"
+    - "hurts when i press on it"
+    - "goes away if i stop"
+    # --- screening denial coverage ---
+    - "no chest pain or"
+    - "no chest pain and no"
+    - "no chest pain like"
+    - "none of that"
+    - "not having any chest"
+    - "no pain no pressure"
+    - "chest feels normal"
+    - "no tightness in my chest"
+    - "no heaviness in my chest"
+    - "chest is not hurting"
+    - "no issues with my chest"
+    # --- medication/question context (reproducible_chest_discomfort R1) ---
+    - "chest pain medication"
+    - "medication for my chest"
+    - "medication for chest pain"
+    - "asking about my angina"
+    - "question about nitroglycerin"
+    - "nitroglycerin timing"
+    - "nitroglycerin schedule"
+    - "when to take my nitroglycerin"
+    - "stable angina"
+    - "my angina medication"
+    - "angina is stable"
+    - "managing my angina"
+    - "managing my chest"
+    - "my usual chest"
+    - "my regular chest"
+    - "my known chest"
+    - "predictable chest"
+    - "been managing this"
+    - "refill for chest"
+    - "chest pain is controlled"
+    - "on medication for my chest"
+    # --- musculoskeletal/reproducible context ---
+    - "chest wall"
+    - "chest wall pain"
+    - "same spot every time"
+    - "same exact spot"
+    - "can reproduce it"
+    - "can make it happen"
+    - "I can trigger it"
+    - "ice helps"
+    - "nsaid"
+    - "ibuprofen helps"
+    - "naproxen helps"
+    - "anti-inflammatory helps"
+    - "started after lifting"
+    - "started after carrying"
+    - "started after moving"
+    - "rib injury"
+    - "bruised rib"
+    - "strained muscle"
+    - "muscle strain"
+    - "physical therapy for my chest"
+    - "exercises for my chest"
+    - "stretching helps"
+    - "chest exercises"
+    - "the spot where it hurts"
+    - "only hurts when I touch"
+    - "only hurts when I push"
+    - "sharp when I twist"
+    - "sharp when I turn"
+    - "popping in my chest"
+    - "clicking in my chest"
+    # --- historical context (FDA-safe: keyword detection) ---
+    - "years ago"
+    - "in the past"
+    - "had this before"
+    - "history of chest"
+    - "used to have chest"
+    - "back when I had"
+    - "previously had"
+    - "past chest pain"
+    - "old chest pain"
+    # --- experiencer context (FDA-safe: keyword detection) ---
+    - "my mother had"
+    - "my father had"
+    - "my mom had"
+    - "my dad had"
+    - "my grandmother had"
+    - "my grandfather had"
+    - "asking for a friend"
+    - "someone I know"
+    - "my spouse has"
+    - "my wife has"
+    - "my husband has"
+    # --- administrative context (FDA-safe: keyword detection) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "routine check"
+    - "just a question"
+    - "routine checkup"
+    - "annual physical"
+    - "wellness visit"
+    - "medication refill"
+    - "appointment timing"
+  # Changed to 'suppress' for R1 false escalation reduction.
+  # Reproducible/positional/musculoskeletal context should suppress chest_pain domain
+  # to prevent false escalation on R1 reproducible_chest_discomfort scenarios.
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_has_condition: ["I25.*"]
+      reason: "Known CAD increases chest pain significance"
+    - when:
+        patient_has_condition: ["I48.*"]
+      reason: "Atrial fibrillation increases thromboembolic risk"
diff --git a/list/taxonomy/cognitive_concern/flows/clarify.yaml b/list/taxonomy/cognitive_concern/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f14db896063c84d7d4052909dae499c242c7d242
--- /dev/null
+++ b/list/taxonomy/cognitive_concern/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: cognitive_concern
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: cognitive_concern_clarify
+      goal: "Ask patient to describe their memory or thinking concerns in more detail"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "dementia"
+      max_questions: 1
+    collects:
+      - cognitive_concern_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/cognitive_concern/flows/concern_assessment.yaml b/list/taxonomy/cognitive_concern/flows/concern_assessment.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1f1222f8d7340662144b34870a9e15ae684045d1
--- /dev/null
+++ b/list/taxonomy/cognitive_concern/flows/concern_assessment.yaml
@@ -0,0 +1,53 @@
+flow_id: concern_assessment
+type: assessment
+domain: cognitive_concern
+
+required_slots:
+  - cognitive_severity
+  - cognitive_duration
+  - daily_impact
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: cognitive_concern_assess_step1
+      goal: "Understand the severity and duration of the patient's memory or confusion issues"
+      tone: warm_empathetic
+      must_include:
+        - "understand"
+      must_ask:
+        - "Can you tell me more about the memory or thinking difficulties you've been having?"
+        - "How long has this been going on?"
+      must_not:
+        - "dementia"
+        - "Alzheimer"
+        - "losing your mind"
+      max_questions: 2
+    collects:
+      - cognitive_severity
+      - cognitive_duration
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: cognitive_concern_assess_step2
+      goal: "Assess impact on daily activities and whether the patient has support"
+      tone: warm_empathetic
+      must_include:
+        - "daily life"
+      must_ask:
+        - "Has this affected your ability to manage daily tasks like cooking, medications, or getting around?"
+      must_not:
+        - "dementia"
+        - "can't live alone"
+        - "nursing home"
+      max_questions: 1
+    collects:
+      - daily_impact
+
+exit:
+  on_complete: evaluate_concern
+  on_concern: handoff
+  on_low_risk: reassure_low_risk
+  on_unclear: handoff
diff --git a/list/taxonomy/cognitive_concern/flows/reassure_low_risk.yaml b/list/taxonomy/cognitive_concern/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e3ead486e94fa9463792b5a2a93c260aceca580e
--- /dev/null
+++ b/list/taxonomy/cognitive_concern/flows/reassure_low_risk.yaml
@@ -0,0 +1,22 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: cognitive_concern
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: cognitive_concern_reassure
+      goal: "Acknowledge the patient's concerns about memory, note that mild changes can be normal, and ensure their care team will be informed"
+      tone: warm_empathetic
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "nothing to worry about"
+        - "dementia"
+        - "normal for your age"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/cognitive_concern/rules.yaml b/list/taxonomy/cognitive_concern/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..89798123b83faf2173854f1e02c4dc4c2641b173
--- /dev/null
+++ b/list/taxonomy/cognitive_concern/rules.yaml
@@ -0,0 +1,27 @@
+domain: cognitive_concern
+target_risk_class: R1
+
+decision_rules:
+  - id: cognitive_concern_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: concern_assessment
+
+  - id: cognitive_concern_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: concern_assessment
+
+  - id: cognitive_concern_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: cognitive_concern_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/cognitive_concern/triggers.yaml b/list/taxonomy/cognitive_concern/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a4cbf1ef12745653bacf733e4722bc9467139c9c
--- /dev/null
+++ b/list/taxonomy/cognitive_concern/triggers.yaml
@@ -0,0 +1,70 @@
+domain: cognitive_concern
+priority: 35
+
+lexical_signals:
+  high:
+    phrases:
+      - "can't remember anything"
+      - "getting lost in my own house"
+      - "forgot where I am"
+      - "don't know what day it is"
+      - "memory is getting really bad"
+      - "keep forgetting my medications"
+      - "getting confused all the time"
+      - "can't remember my doctor's name"
+      - "lost and confused"
+      - "don't recognize people"
+      - "forgetting how to do things"
+      - "can't remember how to get home"
+      - "memory is much worse"
+      - "confused about where I am"
+      - "keep getting lost"
+    regex:
+      - "(can't|cannot|unable\\s+to)\\s+remember.{0,20}(anything|names|where|what|how)"
+      - "(getting|keep|always)\\s+(lost|confused|disoriented).{0,15}(house|home|neighborhood|familiar)"
+      - "memory.{0,15}(really|much|significantly|noticeably).{0,10}(bad|worse|declining|poor)"
+      - "(forget|forgot|forgetting).{0,15}(medication|medicine|pills|appointments|people|names)"
+  medium:
+    phrases:
+      - "memory issues"
+      - "getting confused"
+      - "forgetting things"
+      - "can't remember"
+      - "trouble remembering"
+      - "mind is foggy"
+      - "having trouble thinking"
+      - "memory isn't what it used to be"
+      - "forgetful lately"
+      - "confused sometimes"
+      - "trouble concentrating"
+      - "brain fog"
+      - "losing my train of thought"
+    regex:
+      - "(memory|remember).{0,15}(issue|problem|trouble|difficult|concern|worry)"
+      - "(confused|confusion|forgetful).{0,10}(lately|recently|sometimes|often)"
+      - "(trouble|difficulty|hard\\s+time).{0,10}(remember|thinking|concentrat)"
+  low:
+    partials:
+      - "forgetful"
+      - "memory"
+      - "confused"
+      - "foggy thinking"
+      - "scatterbrained"
+
+negation_handling:
+  patterns:
+    - "memory is fine"
+    - "no memory issues"
+    - "not confused"
+    - "thinking clearly"
+    - "sharp as a tack"
+    - "no trouble remembering"
+    - "memory is good"
+    - "not forgetful"
+    - "mind is clear"
+    - "no confusion"
+    - "remembering everything fine"
+    - "thinking is clear"
+    - "not having memory problems"
+    - "brain is working fine"
+  action: downgrade_confidence
diff --git a/list/taxonomy/copd_acute_respiratory/flows/clarify_acute_respiratory.yaml b/list/taxonomy/copd_acute_respiratory/flows/clarify_acute_respiratory.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d2823bedbe7ee364f8c1a0648ed43b97d00fe3f8
--- /dev/null
+++ b/list/taxonomy/copd_acute_respiratory/flows/clarify_acute_respiratory.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify_acute_respiratory
+type: clarification
+domain: copd_acute_respiratory
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: copd_acute_respiratory_clarify
+      goal: "Ask patient to describe their acute breathing difficulty more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - copd_acute_respiratory_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: escalate_respiratory_emergency
diff --git a/list/taxonomy/copd_acute_respiratory/flows/escalate_r3.yaml b/list/taxonomy/copd_acute_respiratory/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..34c568561cb4f559eb68271ad2963a5cf01ed15d
--- /dev/null
+++ b/list/taxonomy/copd_acute_respiratory/flows/escalate_r3.yaml
@@ -0,0 +1,27 @@
+flow_id: escalate_r3
+type: escalation
+domain: copd_acute_respiratory
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Instruct patient to call 911 or go to the emergency department immediately
+      for acute respiratory distress related to COPD
+    tone: calm_urgent
+    must_include:
+    - call 911
+    - emergency
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably nothing
+    - wait and see
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+exit:
+  on_complete: end
diff --git a/list/taxonomy/copd_acute_respiratory/flows/escalate_respiratory_emergency.yaml b/list/taxonomy/copd_acute_respiratory/flows/escalate_respiratory_emergency.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3294d6642b9383c7b17384b9fb5c1d9db9842c57
--- /dev/null
+++ b/list/taxonomy/copd_acute_respiratory/flows/escalate_respiratory_emergency.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_respiratory_emergency
+type: escalation
+domain: copd_acute_respiratory
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: copd_r3_escalation_notice
+    goal: Inform patient this requires immediate emergency attention
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: copd_r3_handoff
+    goal: Transfer to clinical nurse with respiratory emergency context
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/copd_acute_respiratory/flows/screen_acute_respiratory.yaml b/list/taxonomy/copd_acute_respiratory/flows/screen_acute_respiratory.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3088607fdafb97dad3e46548b0c27d3e792eca30
--- /dev/null
+++ b/list/taxonomy/copd_acute_respiratory/flows/screen_acute_respiratory.yaml
@@ -0,0 +1,30 @@
+flow_id: screen_acute_respiratory
+type: screening
+domain: copd_acute_respiratory
+
+required_slots:
+  - respiratory_severity
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: copd_acute_screen_step1
+      goal: "Quickly assess severity of respiratory distress"
+      tone: calm_urgent
+      must_include:
+        - "breathing"
+      must_ask:
+        - "Can you speak in full sentences right now?"
+        - "Are your lips or fingertips turning blue or grey?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - respiratory_severity
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_respiratory_emergency
+  on_unclear: escalate_respiratory_emergency
diff --git a/list/taxonomy/copd_acute_respiratory/rules.yaml b/list/taxonomy/copd_acute_respiratory/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..60c27fe0356b678b1b9b63b29510a1a1dc0106e9
--- /dev/null
+++ b/list/taxonomy/copd_acute_respiratory/rules.yaml
@@ -0,0 +1,27 @@
+domain: copd_acute_respiratory
+target_risk_class: R3
+
+decision_rules:
+  - id: copd_acute_respiratory_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_respiratory_emergency
+
+  - id: copd_acute_respiratory_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: screen_acute_respiratory
+
+  - id: copd_acute_respiratory_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify_acute_respiratory
+
+  - id: copd_acute_respiratory_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_respiratory_emergency
diff --git a/list/taxonomy/copd_acute_respiratory/triggers.yaml b/list/taxonomy/copd_acute_respiratory/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e98bea6d4701e1b102b8584663e364c9a32ea9e3
--- /dev/null
+++ b/list/taxonomy/copd_acute_respiratory/triggers.yaml
@@ -0,0 +1,60 @@
+domain: copd_acute_respiratory
+priority: 96
+
+lexical_signals:
+  high:
+    phrases:
+      - "COPD and I can't breathe at all"
+      - "emphysema and I'm gasping"
+      - "lips are turning blue"
+      - "fingertips are blue"
+      - "COPD and I need an ambulance"
+      - "can't breathe and I have emphysema"
+      - "severe COPD attack"
+      - "COPD emergency"
+      - "skin is turning blue"
+      - "I'm suffocating and I have COPD"
+      - "oxygen isn't helping anymore"
+      - "COPD and I need to call 911"
+      - "gasping for air with my COPD"
+      - "can barely breathe at all"
+      - "cyanotic"
+    regex:
+      - "(?:copd|emphysema).{0,30}(?:can't breathe|gasping|severe|emergency|ambulance|911|suffocat)"
+      - "blue.{0,15}(?:lips|fingertips|skin|nail|face)"
+      - "(?:copd|emphysema).{0,20}(?:emergency|ambulance|911)"
+      - "(?:cyanotic|cyanosis)"
+      - "(?:can't|cannot).{0,10}(?:breathe|get air).{0,10}(?:at all|anymore)"
+  medium:
+    phrases:
+      - "breathing has gotten much worse suddenly"
+      - "oxygen doesn't seem to be helping"
+      - "significantly worse breathing"
+      - "drastically harder to breathe"
+      - "maxed out my oxygen"
+      - "breathing is much much worse"
+      - "can barely talk because of breathing"
+      - "breathing deteriorated fast"
+    regex:
+      - "breathing.{0,20}(?:much worse|significantly|drastically|sudden|rapid)"
+      - "oxygen.{0,15}(?:not helping|doesn't help|maxed|not enough|isn't working)"
+      - "(?:can barely|can hardly).{0,10}(?:talk|speak|breathe)"
+      - "(?:breath|breathing).{0,15}(?:deteriorat|declin|crash)"
+
+negation_handling:
+  patterns:
+    - "breathing is stable"
+    - "no acute distress"
+    - "oxygen is helping"
+    - "breathing improved"
+    - "not an emergency"
+    - "lips are normal color"
+    - "no blue discoloration"
+    - "COPD is controlled"
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_has_condition: ["J44.*"]
+      reason: "Known COPD patient with acute respiratory distress signals"
diff --git a/list/taxonomy/copd_education/flows/copd_diagnosis_teachback.yaml b/list/taxonomy/copd_education/flows/copd_diagnosis_teachback.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..eb87896deaade170165777191aff15fd3c7dd06d
--- /dev/null
+++ b/list/taxonomy/copd_education/flows/copd_diagnosis_teachback.yaml
@@ -0,0 +1,47 @@
+flow_id: copd_diagnosis_teachback
+type: ask
+domain: copd_education
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: copd_teachback_understanding
+      goal: "Ask the patient to explain in their own words what they understand about COPD and how it affects their breathing and lungs"
+      tone: warm_curious
+      must_include:
+        - "own words"
+        - "COPD"
+      must_ask:
+        - "what do you understand about COPD and how it affects your breathing"
+      must_not:
+        - "diagnos"
+        - "change your medications"
+        - "adjust"
+        - "prescribe"
+        - "call 911"
+        - "emergency"
+      max_questions: 1
+    collects:
+      - copd_understanding
+
+  - step: 2
+    type: respond
+    response_spec:
+      id: copd_teachback_reinforce
+      goal: "Acknowledge the patient's understanding and reinforce that COPD is a condition where the airways and air sacs in the lungs are damaged, limiting airflow and making breathing harder over time. Explain that symptoms include shortness of breath, cough, and fatigue, and that managing it well with smoking cessation and proper inhaler use can help them stay active"
+      tone: warm_supportive
+      must_include:
+        - "airways"
+        - "airflow"
+        - "breathing"
+        - "manage"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "change your medications"
+        - "adjust"
+        - "prescribe"
+        - "call 911"
+        - "emergency"
+      max_questions: 1
diff --git a/list/taxonomy/copd_education/flows/copd_nicotine_patch.yaml b/list/taxonomy/copd_education/flows/copd_nicotine_patch.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9676d83cc866a595ef7f1a7ca4b350368b00637d
--- /dev/null
+++ b/list/taxonomy/copd_education/flows/copd_nicotine_patch.yaml
@@ -0,0 +1,68 @@
+flow_id: copd_nicotine_patch
+type: ask
+domain: copd_education
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: copd_patch_current_use
+      goal: "Ask the patient whether they have been using their nicotine patch and if they have any questions about how to use it"
+      tone: warm_curious
+      must_include:
+        - "nicotine patch"
+      must_ask:
+        - "have you been using your nicotine patch"
+      must_not:
+        - "diagnos"
+        - "change your medications"
+        - "adjust"
+        - "prescribe"
+        - "call 911"
+        - "emergency"
+      max_questions: 1
+    collects:
+      - patch_use_status
+
+  - step: 2
+    type: respond
+    response_spec:
+      id: copd_patch_instructions
+      goal: "Review nicotine patch usage including the step-down schedule: starting at 21mg, stepping down to 14mg, then 7mg over an 8 to 12 week course. Apply to clean, dry, hairless skin on the upper body or upper arm, rotate the site each day, press firmly for ten seconds, and remove the old patch before applying a new one each morning"
+      tone: warm_professional
+      must_include:
+        - "clean"
+        - "dry"
+        - "rotate"
+        - "patch"
+        - "21"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "change your medications"
+        - "adjust"
+        - "prescribe"
+        - "call 911"
+        - "emergency"
+      max_questions: 1
+
+  - step: 3
+    type: ask
+    response_spec:
+      id: copd_patch_side_effects
+      goal: "Ask the patient if they have noticed any skin irritation at the patch site (the most common side effect) or trouble sleeping, especially if wearing the patch overnight. Mention that rotating the site daily helps with irritation and removing the patch before bed can help with sleep"
+      tone: warm_curious
+      must_include:
+        - "patch"
+      must_ask:
+        - "have you noticed any skin irritation or other concerns with the patch"
+      must_not:
+        - "diagnos"
+        - "change your medications"
+        - "adjust"
+        - "prescribe"
+        - "call 911"
+        - "emergency"
+      max_questions: 1
+    collects:
+      - patch_side_effects
diff --git a/list/taxonomy/copd_education/flows/copd_smoking_education.yaml b/list/taxonomy/copd_education/flows/copd_smoking_education.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4160be6275f1e3788cafb923dfe5d41ced3ce1f1
--- /dev/null
+++ b/list/taxonomy/copd_education/flows/copd_smoking_education.yaml
@@ -0,0 +1,46 @@
+flow_id: copd_smoking_education
+type: ask
+domain: copd_education
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: copd_smoking_status
+      goal: "Ask the patient about their current smoking status and whether they have been able to avoid smoking since discharge"
+      tone: warm_curious
+      must_include:
+        - "smoking"
+      must_ask:
+        - "have you been able to stay away from smoking"
+      must_not:
+        - "diagnos"
+        - "change your medications"
+        - "adjust"
+        - "prescribe"
+        - "call 911"
+        - "emergency"
+      max_questions: 1
+    collects:
+      - smoking_status
+
+  - step: 2
+    type: respond
+    response_spec:
+      id: copd_smoking_importance
+      goal: "Explain the importance of not smoking with COPD: quitting smoking is the single most effective intervention to slow COPD progression, reduce exacerbations, and improve daily symptoms like cough and shortness of breath. Smoking speeds up airway damage and lung function decline. It is never too late to benefit from stopping"
+      tone: warm_supportive
+      must_include:
+        - "airway"
+        - "quitting"
+        - "COPD"
+        - "slow"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "change your medications"
+        - "adjust"
+        - "prescribe"
+        - "call 911"
+        - "emergency"
+      max_questions: 1
diff --git a/list/taxonomy/copd_education/flows/edu_final_summary_copd.yaml b/list/taxonomy/copd_education/flows/edu_final_summary_copd.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..249da2d0b39c5565bdf8ce93c50e7d532635c4bb
--- /dev/null
+++ b/list/taxonomy/copd_education/flows/edu_final_summary_copd.yaml
@@ -0,0 +1,27 @@
+flow_id: edu_final_summary_copd
+type: respond
+domain: copd_education
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: copd_edu_summary
+      goal: "Summarize the key education points covered: COPD is a condition that damages the airways and air sacs limiting airflow, quitting smoking is the single most effective step to slow COPD progression, and the nicotine patch step-down schedule from 21mg to 14mg to 7mg over 8-12 weeks with site rotation. Thank the patient for their time and encourage them to reach out to their care team with any questions"
+      tone: warm_professional
+      must_include:
+        - "COPD"
+        - "airflow"
+        - "smoking"
+        - "nicotine patch"
+        - "care team"
+        - "thank you"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "change your medications"
+        - "adjust"
+        - "prescribe"
+        - "call 911"
+        - "emergency"
+      max_questions: 0
diff --git a/list/taxonomy/copd_education/flows/edu_intro_copd.yaml b/list/taxonomy/copd_education/flows/edu_intro_copd.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0534bda8902275f625d539caa4e8da1d742c6cda
--- /dev/null
+++ b/list/taxonomy/copd_education/flows/edu_intro_copd.yaml
@@ -0,0 +1,26 @@
+flow_id: edu_intro_copd
+type: ask
+domain: copd_education
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: copd_edu_intro
+      goal: "Introduce yourself and explain you will be reviewing some important information about COPD management with the patient"
+      tone: warm_professional
+      must_include:
+        - "COPD"
+        - "education"
+      must_ask:
+        - "walk through some important information about managing your COPD"
+      must_not:
+        - "diagnos"
+        - "change your medications"
+        - "adjust"
+        - "prescribe"
+        - "call 911"
+        - "emergency"
+      max_questions: 1
+    collects:
+      - edu_consent
diff --git a/list/taxonomy/copd_education/rules.yaml b/list/taxonomy/copd_education/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..608f3f52adb52b60f122d4d628e4d7281edb86ec
--- /dev/null
+++ b/list/taxonomy/copd_education/rules.yaml
@@ -0,0 +1,32 @@
+domain: copd_education
+
+decision_rules:
+  - id: copd_edu_intro
+    if:
+      agenda_step: edu_intro
+    then:
+      flow: edu_intro_copd
+
+  - id: copd_diagnosis_understanding
+    if:
+      agenda_step: diagnosis_understanding
+    then:
+      flow: copd_diagnosis_teachback
+
+  - id: copd_smoking_cessation
+    if:
+      agenda_step: smoking_cessation
+    then:
+      flow: copd_smoking_education
+
+  - id: copd_nicotine_patch_use
+    if:
+      agenda_step: nicotine_patch_use
+    then:
+      flow: copd_nicotine_patch
+
+  - id: copd_summary_note
+    if:
+      agenda_step: summary_note
+    then:
+      flow: edu_final_summary_copd
diff --git a/list/taxonomy/copd_education/triggers.yaml b/list/taxonomy/copd_education/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..52b14b2d1d9d447def53510839c93c613d24d2f7
--- /dev/null
+++ b/list/taxonomy/copd_education/triggers.yaml
@@ -0,0 +1,7 @@
+domain: copd_education
+priority: 0
+
+# Empty signals — this domain is agenda-driven, not nomination-driven.
+# It becomes the default control path for COPD patient education calls.
+# The engine activates it by setting agenda_step, not through lexical nomination.
+lexical_signals: {}
diff --git a/list/taxonomy/copd_exacerbation/flows/clarify_copd.yaml b/list/taxonomy/copd_exacerbation/flows/clarify_copd.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4bf0475f0886cb4bd0ae509d37d55a2852675cae
--- /dev/null
+++ b/list/taxonomy/copd_exacerbation/flows/clarify_copd.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify_copd
+type: clarification
+domain: copd_exacerbation
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: copd_exacerbation_clarify
+      goal: "Ask patient to describe their COPD symptoms more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - copd_exacerbation_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/copd_exacerbation/flows/escalate_copd.yaml b/list/taxonomy/copd_exacerbation/flows/escalate_copd.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7fb8b7bb0dd2bbdd30f5df1431c116e02eee5293
--- /dev/null
+++ b/list/taxonomy/copd_exacerbation/flows/escalate_copd.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_copd
+type: escalation
+domain: copd_exacerbation
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: copd_r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their COPD symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: copd_r2_handoff
+      goal: "Schedule same-day nurse callback with COPD exacerbation context"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/copd_exacerbation/flows/escalate_r2.yaml b/list/taxonomy/copd_exacerbation/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9d0839dcf90723431c451f9f33d08af095f78fff
--- /dev/null
+++ b/list/taxonomy/copd_exacerbation/flows/escalate_r2.yaml
@@ -0,0 +1,24 @@
+flow_id: escalate_r2
+type: escalation
+domain: copd_exacerbation
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient about urgency of their COPD exacerbation symptoms and transfer to a clinical team member for same-day evaluation"
+      tone: calm_direct
+      must_include:
+        - "nurse"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably nothing"
+        - "wait and see"
+      max_questions: 0
+
+exit:
+  on_complete: handoff
diff --git a/list/taxonomy/copd_exacerbation/flows/handoff.yaml b/list/taxonomy/copd_exacerbation/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..17ea05219fc6e8b39f3bc952ed40e74c10315f58
--- /dev/null
+++ b/list/taxonomy/copd_exacerbation/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: copd_exacerbation
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: copd_exacerbation_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: copd_exacerbation_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/copd_exacerbation/flows/reassure_copd.yaml b/list/taxonomy/copd_exacerbation/flows/reassure_copd.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1fdc4a55bfeb098375b3f8441b5ec4a66a5a29e6
--- /dev/null
+++ b/list/taxonomy/copd_exacerbation/flows/reassure_copd.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_copd
+type: resolution
+domain: copd_exacerbation
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: copd_reassure
+      goal: "Acknowledge the patient's COPD concern, note that their care team will be informed for routine follow-up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/copd_exacerbation/flows/screen_copd_status.yaml b/list/taxonomy/copd_exacerbation/flows/screen_copd_status.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..af2e79f9d9f2df9d89fc83fc2de17e6f3b0247b6
--- /dev/null
+++ b/list/taxonomy/copd_exacerbation/flows/screen_copd_status.yaml
@@ -0,0 +1,50 @@
+flow_id: screen_copd_status
+type: screening
+domain: copd_exacerbation
+
+required_slots:
+  - zone_classification
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: copd_screen_step1
+      goal: "Assess COPD zone status (green/yellow/red) and medication changes"
+      tone: calm_urgent
+      must_include:
+        - "breathing"
+      must_ask:
+        - "How would you describe your breathing right now compared to your normal baseline?"
+        - "Have there been any changes to your COPD medications recently?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - zone_classification
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: copd_screen_step2
+      goal: "Assess oxygen use and activity tolerance"
+      tone: calm_urgent
+      must_include:
+        - "understand"
+      must_ask:
+        - "Are you using supplemental oxygen, and if so has your need changed?"
+        - "How far can you walk or what activities can you do before getting short of breath?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - oxygen_use
+      - activity_tolerance
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_copd
+  on_low_risk: reassure_copd
+  on_unclear: clarify_copd
diff --git a/list/taxonomy/copd_exacerbation/rules.yaml b/list/taxonomy/copd_exacerbation/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5cbb79d37d94a0cdc814d732fcc052fc22a1d1b7
--- /dev/null
+++ b/list/taxonomy/copd_exacerbation/rules.yaml
@@ -0,0 +1,27 @@
+domain: copd_exacerbation
+target_risk_class: R2
+
+decision_rules:
+  - id: copd_exacerbation_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: screen_copd_status
+
+  - id: copd_exacerbation_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: screen_copd_status
+
+  - id: copd_exacerbation_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify_copd
+
+  - id: copd_exacerbation_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_copd
diff --git a/list/taxonomy/copd_exacerbation/triggers.yaml b/list/taxonomy/copd_exacerbation/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..18bc704660a7f2ffd03e02b8b404dcaed4209e22
--- /dev/null
+++ b/list/taxonomy/copd_exacerbation/triggers.yaml
@@ -0,0 +1,103 @@
+domain: copd_exacerbation
+priority: 73
+
+lexical_signals:
+  high:
+    phrases:
+      - "COPD is getting worse"
+      - "emphysema flare up"
+      - "can't breathe and I have COPD"
+      - "sputum turned green"
+      - "coughing up yellow thick mucus"
+      - "COPD exacerbation"
+      - "can't catch my breath and my COPD is acting up"
+      - "sputum is bloody"
+      - "brown phlegm and breathing is terrible"
+      - "emphysema is worse than ever"
+      - "lungs are really bad today"
+      - "can't stop coughing and can't breathe"
+      - "COPD attack"
+      - "breathing has gotten much worse with my COPD"
+      - "coughing up thick green stuff"
+    regex:
+      - "(?:copd|emphysema).{0,30}(?:worse|flare|exacerbat|attack|act)"
+      - "(?:can't|cannot|unable).{0,15}(?:breathe|catch).{0,10}(?:breath)"
+      - "sputum.{0,15}(?:green|yellow|brown|bloody|thick|pus)"
+      - "(?:copd|emphysema).{0,20}(?:bad|terrible|awful|horrible)"
+      - "(?:cough|hack).{0,15}(?:up|ing).{0,15}(?:green|yellow|brown|blood|thick)"
+  medium:
+    phrases:
+      - "wheezing is getting worse"
+      - "coughing more than usual"
+      - "using my rescue inhaler more often"
+      - "albuterol every few hours"
+      - "chest feels tighter with my COPD"
+      - "more phlegm than usual"
+      - "harder to breathe the last few days"
+      - "nebulizer not helping as much"
+      - "winded doing simple things"
+      - "COPD symptoms are increasing"
+      - "breathing is harder than it was"
+      - "more short of breath lately"
+      - "inhaler doesn't seem to be working"
+      - "mucus production is up"
+      - "cough keeps getting worse"
+      # --- MINIMIZER coverage ---
+      - "just a little more phlegm than usual"
+      - "cough is maybe a bit worse"
+      - "probably just the weather affecting my breathing"
+      - "inhaler use might be up a little"
+    regex:
+      - "(?:wheez|cough).{0,20}(?:worse|increase|more|bad)"
+      - "using.{0,15}(?:rescue|albuterol|inhaler|nebulizer).{0,15}(?:more|often|frequent|every)"
+      - "(?:phlegm|mucus|sputum).{0,15}(?:more|increase|worse|thicker)"
+      - "(?:chest|lung).{0,15}(?:tight|congested|heavy)"
+      - "(?:breath|breathing).{0,15}(?:harder|worse|difficult|struggle)"
+      - "(?:just|only).{0,10}(?:a\\s+)?(?:little|bit).{0,10}(?:more|worse).{0,15}(?:cough|phlegm|wheez|breath)"
+  low:
+    partials:
+      - "more cough"
+      - "more phlegm"
+      - "more mucus"
+      - "chest tight"
+      - "COPD"
+      - "emphysema"
+      - "chronic bronchitis"
+      - "rescue inhaler"
+      - "nebulizer"
+      - "wheezing"
+      - "sputum"
+
+negation_handling:
+  patterns:
+    - "COPD is stable"
+    - "breathing is the same"
+    - "no change in symptoms"
+    - "cough is the same"
+    - "sputum is clear"
+    - "inhaler use is unchanged"
+    - "COPD is well controlled"
+    - "breathing has improved"
+    - "no worse than usual"
+    - "lungs sound clear"
+    - "no increase in mucus"
+    - "wheezing has stopped"
+    - "COPD check-up"
+    - "routine COPD visit"
+    # --- administrative context ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_has_condition: ["J44.*", "J43.*"]
+      reason: "Known COPD/emphysema patient with respiratory complaints"
+  boost_to_medium:
+    - when:
+        patient_has_condition: ["J44.*"]
+      reason: "COPD history raises baseline concern for exacerbation"
diff --git a/list/taxonomy/cssrs_suicide_screen/flows/clarify.yaml b/list/taxonomy/cssrs_suicide_screen/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f6856638004d2d4ee2286a2bbfdd84b57306e1c6
--- /dev/null
+++ b/list/taxonomy/cssrs_suicide_screen/flows/clarify.yaml
@@ -0,0 +1,26 @@
+flow_id: clarify
+type: clarification
+domain: cssrs_suicide_screen
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: cssrs_clarify
+      goal: "Gently ask patient to describe what they are experiencing"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+        - "safe"
+      must_ask:
+        - "I want to make sure I understand what you're going through. Could you tell me a bit more about how you've been feeling?"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - cssrs_clarify_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: escalate_r2
diff --git a/list/taxonomy/cssrs_suicide_screen/flows/cssrs_screen.yaml b/list/taxonomy/cssrs_suicide_screen/flows/cssrs_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1d07557fe7f8a5ddd59212e1a1ade353f88554d1
--- /dev/null
+++ b/list/taxonomy/cssrs_suicide_screen/flows/cssrs_screen.yaml
@@ -0,0 +1,80 @@
+flow_id: cssrs_screen
+type: screening
+domain: cssrs_suicide_screen
+
+# C-SSRS Community Card 6-question structured screening.
+# Q1: Wish to be dead. Q2: Suicidal thoughts. Q3: Method (if Q2=yes).
+# Q4: Intent. Q5: Plan details. Q6: Any preparatory behavior.
+
+required_slots:
+  - cssrs_q1_wish_dead
+  - cssrs_q2_thoughts_killing
+  - cssrs_q6_any_behavior
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: cssrs_screen_q1_q2
+      goal: "C-SSRS Q1 and Q2: screen for wish to be dead and active suicidal thoughts"
+      tone: gentle_professional
+      must_include:
+        - "understand"
+        - "safe"
+      must_ask:
+        - "Have you wished you were dead or wished you could go to sleep and not wake up?"
+        - "Have you actually had any thoughts of killing yourself?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+        - "diagnos"
+      max_questions: 2
+    collects:
+      - cssrs_q1_wish_dead
+      - cssrs_q2_thoughts_killing
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: cssrs_screen_q3_q4
+      goal: "C-SSRS Q3 and Q4: screen for method and intent"
+      tone: gentle_professional
+      must_include:
+        - "understand"
+      must_ask:
+        - "Have you been thinking about how you might do this?"
+        - "Have you had any intention of acting on these thoughts?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+        - "diagnos"
+      max_questions: 2
+    collects:
+      - cssrs_q3_method
+      - cssrs_q4_intent
+
+  - step: 3
+    type: ask
+    response_spec:
+      id: cssrs_screen_q5_q6
+      goal: "C-SSRS Q5 and Q6: screen for plan details and any behavior or preparation"
+      tone: gentle_professional
+      must_include:
+        - "important"
+      must_ask:
+        - "Have you started to work out the details of how to do this, or made any specific plans?"
+        - "Have you done anything, started to do anything, or prepared to do anything to end your life?"
+      must_not:
+        - "don't worry"
+        - "diagnos"
+      max_questions: 2
+    collects:
+      - cssrs_q5_plan
+      - cssrs_q6_any_behavior
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_r2: escalate_r2
+  on_low_risk: handoff
+  on_unclear: escalate_r2
diff --git a/list/taxonomy/cssrs_suicide_screen/flows/escalate_r2.yaml b/list/taxonomy/cssrs_suicide_screen/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..01f23b9d01ff4e927d066e600e5bfe9382300540
--- /dev/null
+++ b/list/taxonomy/cssrs_suicide_screen/flows/escalate_r2.yaml
@@ -0,0 +1,36 @@
+flow_id: escalate_r2
+type: escalation
+domain: cssrs_suicide_screen
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: cssrs_r2_escalation_notice
+      goal: "Connect patient with mental health professional for same-day evaluation"
+      tone: empathetic
+      must_include:
+        - "mental health"
+        - "today"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: mental_health_professional
+    urgency: same_day
+    response_spec:
+      id: cssrs_r2_handoff
+      goal: "Transfer to mental health professional"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/cssrs_suicide_screen/flows/escalate_r3.yaml b/list/taxonomy/cssrs_suicide_screen/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d69f27d0c90f4ede9779b6cdde0ebc2d02cc4bb1
--- /dev/null
+++ b/list/taxonomy/cssrs_suicide_screen/flows/escalate_r3.yaml
@@ -0,0 +1,41 @@
+flow_id: escalate_r3
+type: escalation
+domain: cssrs_suicide_screen
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: cssrs_r3_escalation_notice
+    goal: Immediate crisis intervention — reference 988 Suicide and Crisis Lifeline
+      and connect to crisis counselor
+    tone: calm_urgent
+    must_include:
+    - '988'
+    - call 911
+    - right now
+    - crisis
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: crisis_counselor
+  urgency: immediate
+  response_spec:
+    id: cssrs_r3_handoff
+    goal: Transfer to crisis counselor immediately
+    tone: professional
+    must_include:
+    - transferring
+    - crisis counselor
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/cssrs_suicide_screen/flows/handoff.yaml b/list/taxonomy/cssrs_suicide_screen/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..eb19faa3da872247dd7e5ad422eb4992cbee0ec1
--- /dev/null
+++ b/list/taxonomy/cssrs_suicide_screen/flows/handoff.yaml
@@ -0,0 +1,40 @@
+flow_id: handoff
+type: handoff
+domain: cssrs_suicide_screen
+
+# R1 path: passive ideation only (Q1=yes but Q2=no, Q6=no).
+# Provide 988 resource and schedule behavioral health follow-up within 48h.
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: cssrs_r1_resource_notice
+      goal: "Provide 988 Lifeline resource and behavioral health follow-up"
+      tone: gentle_professional
+      must_include:
+        - "988"
+        - "behavioral health"
+        - "follow-up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "emergency"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: behavioral_health_followup
+    urgency: within_48h
+    response_spec:
+      id: cssrs_r1_handoff
+      goal: "Schedule behavioral health follow-up within 48 hours"
+      tone: professional
+      must_include:
+        - "follow-up"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/cssrs_suicide_screen/rules.yaml b/list/taxonomy/cssrs_suicide_screen/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..72e6214b828a279ccdc33423b501d6fefd18e1d8
--- /dev/null
+++ b/list/taxonomy/cssrs_suicide_screen/rules.yaml
@@ -0,0 +1,33 @@
+domain: cssrs_suicide_screen
+target_risk_class: R2
+
+decision_rules:
+  - id: cssrs_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: cssrs_screen
+
+  - id: cssrs_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: cssrs_screen
+
+  - id: cssrs_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: cssrs_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: cssrs_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/cssrs_suicide_screen/triggers.yaml b/list/taxonomy/cssrs_suicide_screen/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..35e09fa68bdfb347bf39c25ef6475a77c7a454d4
--- /dev/null
+++ b/list/taxonomy/cssrs_suicide_screen/triggers.yaml
@@ -0,0 +1,182 @@
+domain: cssrs_suicide_screen
+priority: 95
+
+# Mirrors suicidal_ideation triggers — same lexical signals trigger the
+# C-SSRS structured screening instead of immediate escalation (when
+# crisis_line wedge is active and hard_escalate_bypass is set).
+
+lexical_signals:
+  high:
+    phrases:
+      - "want to kill myself"
+      - "suicidal thoughts"
+      - "thinking about ending my life"
+      - "don't want to be alive"
+      - "planning to hurt myself"
+      - "want to die"
+      - "going to end it"
+      - "shouldn't be here anymore"
+      - "don't want to be here anymore"
+      - "thinking about not being here"
+      - "don't wanna be here"
+      - "tired of being here"
+      - "won't have to worry about me"
+      - "wish I wouldn't wake up"
+      - "don't want to exist"
+      - "wish I could just not wake up"
+      - "go to sleep and not wake up"
+      - "not wake up tomorrow"
+      - "just not exist anymore"
+      - "staring at pills"
+      - "looking at the bridge"
+      - "have a plan"
+      - "I have a plan"
+      - "know exactly how"
+      - "lethal dosing"
+      - "researching methods"
+      - "looked up lethal"
+      - "end the pain"
+      - "permanent solution"
+      - "make it stop permanently"
+      - "end it all"
+      - "end this suffering"
+      - "final solution"
+      - "only way out"
+      - "everyone better off without me"
+      - "just a burden"
+      - "they'd be better without me"
+      - "life insurance would help them more"
+      - "dragging everyone down"
+      - "no way out"
+      - "nothing matters anymore"
+      - "no point in going on"
+      - "no reason to go on"
+      - "can't see a future"
+      - "no future for me"
+    regex:
+      - "(want|going|plan)\\s+to\\s+(kill|end|hurt)\\s+(myself|my\\s+life|it\\s+all|it)"
+      - "(don'?t|do not)\\s+(want|deserve)\\s+to\\s+(be\\s+alive|live|be\\s+here|exist)"
+      - "(shouldn'?t|should not)\\s+be\\s+here"
+      - "(thinking|thought).{0,10}(about|of).{0,10}(not being here|ending|killing|dying|suicide)"
+      - "(better|easier).{0,20}(off|if).{0,30}(dead|gone|without me|wasn'?t|not here|didn'?t exist)"
+      - "(don'?t|do not|doesn'?t).{0,5}wanna?.{0,5}be\\s+here"
+      - "tired\\s+of\\s+being\\s+here"
+      - "won'?t\\s+have\\s+to\\s+worry"
+      - "what\\s+if\\s+I\\s+(just\\s+)?(wasn'?t|weren'?t|wasn't)\\s+here"
+      - "if\\s+I\\s+(just\\s+)?(stopped|didn'?t|wasn'?t|weren't)"
+      - "(wish|hope|pray|want)\\s+(I\\s+)?(wouldn'?t|didn'?t|don'?t|could\\s+just\\s+not)\\s+(wake|exist|be\\s+here)"
+      - "(go|went)\\s+to\\s+sleep\\s+and\\s+(not|never)\\s+wake"
+      - "not\\s+wake\\s+up\\s+(tomorrow|again|ever)"
+      - "(just\\s+)?not\\s+exist\\s+(anymore|any\\s+more)"
+      - "(staring|stared|looking)\\s+(at|into)\\s+(the\\s+)?(pill|bridge|gun|rope|knife|razor|edge|bottle|medication|balcony|ledge|tracks)"
+      - "(have|got|made)\\s+a\\s+(plan|method|way)"
+      - "(know|figured out|researched)\\s+(exactly\\s+)?how\\s+(I|to)"
+      - "(lethal|fatal)\\s+(dose|dosing|amount)"
+      - "(looked|looking|research)\\s+(up|into)\\s+(lethal|methods|ways\\s+to)"
+      - "(end|stop)\\s+(the|this|my)\\s+(pain|suffering|struggle|misery)"
+      - "(permanent|final)\\s+(solution|answer|escape|rest|relief)"
+      - "(only|no\\s+other)\\s+(way\\s+)?out"
+      - "end\\s+it\\s+all"
+      - "make\\s+it\\s+(all\\s+)?stop"
+      - "(everyone|they|family|my\\s+wife|my\\s+husband|my\\s+kids).{0,20}(better|easier).{0,20}(off|without)\\s+(me|I)"
+      - "(just|nothing\\s+but|only)\\s+a\\s+burden"
+      - "(dragging|bringing|weighing)\\s+(everyone|them|you|my\\s+family)\\s+down"
+      - "life\\s+insurance\\s+would\\s+(help|be\\s+worth)"
+      - "(no|not\\s+any|can'?t\\s+see\\s+a?)\\s+(way\\s+out|future|hope|point|reason)"
+      - "nothing\\s+(matters|will\\s+change|helps)"
+      - "no\\s+point\\s+(in|of|to)\\s+(going\\s+on|living|continuing|trying)"
+      - "no\\s+reason\\s+to\\s+(go\\s+on|live|keep|continue)"
+      - "can'?t\\s+see\\s+(a\\s+)?(future|way\\s+(forward|out)|light)"
+  medium:
+    phrases:
+      - "feel like giving up"
+      - "life isn't worth living"
+      - "thinking about suicide"
+      - "wish I could just disappear"
+      - "better off without me"
+      - "no reason to go on"
+      - "everything would be easier if I wasn't here"
+      - "can't do this anymore"
+      - "don't see the point"
+      - "I just want it to stop"
+      - "I keep thinking I shouldn't be here"
+      - "I said some dumb stuff about not wanting to be around"
+      - "what if I just didn't have to deal"
+      - "just stopped existing"
+      - "if I didn't wake up"
+      - "easier if I just"
+      - "you know what I mean"
+      - "not one of those people but"
+      - "wrote letters"
+      - "tying up loose ends"
+      - "everyone would be better"
+      - "just a burden"
+      - "sleep forever"
+      - "want the pain to stop permanently"
+      - "giving away my things"
+      - "said goodbye to everyone"
+      - "making arrangements"
+      - "put my affairs in order"
+      - "no point in fighting anymore"
+      - "I'm done"
+      - "what's the point"
+    regex:
+      - "(give|giving)\\s+up"
+      - "(no|don'?t\\s+see\\s+a?)\\s+(reason|point|purpose).{0,10}(to|for|in).{0,10}(go on|living|life)"
+      - "(wish|want).{0,15}(disappear|vanish|gone|not exist|not be here|not wake)"
+      - "(can'?t|cannot)\\s+(do|take|handle).{0,10}(this|it|anymore|any more)"
+      - "not\\s+want.{0,15}(to be|being)\\s+(around|here|alive)"
+      - "(should|just).{0,10}(disappear|stop existing|not be here|not wake up)"
+      - "didn'?t\\s+(have to|need to|wake|exist|have to deal)"
+      - "saying.{0,15}(scary|dark|concerning)\\s+(stuff|things).{0,20}(hurt|die|end|kill|alive|living)"
+      - "he.{0,5}(don'?t|doesn'?t|didn'?t).{0,5}(wanna|want to).{0,5}be\\s+here"
+      - "(wish|hope|pray)\\s+(I\\s+)?(wouldn'?t|didn'?t|don'?t)\\s+(wake|exist|have to)"
+      - "(stared at|looking at|holding)\\s+(the\\s+)?(pill|bridge|gun|rope|knife|razor|edge)"
+      - "(heavy|empty|tired|fuzzy|dark).{0,30}(feeling|felt|feels|everything)"
+      - "(stared?\\s+at|looking\\s+at|keep\\s+looking).{0,10}(medication|pill|bottle|drug)"
+      - "everyone\\s+would\\s+be\\s+better\\s+off\\s+without"
+      - "things\\s+have\\s+been\\s+harder"
+      - "can'?t\\s+see\\s+a\\s+way\\s+forward"
+      - "(asking|this is)\\s+(for|about)\\s+a\\s+friend"
+      - "(giving away|gave away|giving out)\\s+(my\\s+)?(things|stuff|belongings|possessions)"
+      - "(wrote|writing|written)\\s+(a\\s+)?(letter|note|goodbye|farewell)"
+      - "(tying|tied|putting)\\s+(up\\s+)?(loose ends|affairs|things in order)"
+  low:
+    partials:
+      - "hopeless"
+      - "suicidal"
+      - "self-harm"
+      - "ending it"
+      - "don't want to be here"
+      - "kill myself"
+      - "not worth living"
+      - "stopped existing"
+      - "wanna disappear"
+      - "not be here"
+      - "passing thought about"
+      - "everyone gets those thoughts"
+      - "not going to do anything but"
+      - "burden"
+      - "what's the point"
+      - "done with everything"
+
+negation_handling:
+  patterns:
+    - "not suicidal"
+    - "no thoughts of self-harm"
+    - "don't want to hurt myself"
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "when can I come in"
+    - "medication refill"
+    - "need a refill"
+    - "routine check"
+    - "just a question"
+    - "appointment timing"
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_has_condition: ["F32.*", "F33.*", "F31.*"]
+      reason: "Depressive/bipolar disorder history increases SI risk"
diff --git a/list/taxonomy/diabetes_management/flows/clarify_diabetes.yaml b/list/taxonomy/diabetes_management/flows/clarify_diabetes.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8da19c7944ed2c3e4f9340352d6a355a69d83399
--- /dev/null
+++ b/list/taxonomy/diabetes_management/flows/clarify_diabetes.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify_diabetes
+type: clarification
+domain: diabetes_management
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: diabetes_management_clarify
+      goal: "Ask patient to describe their diabetes concern more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - diabetes_management_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/diabetes_management/flows/escalate_diabetes.yaml b/list/taxonomy/diabetes_management/flows/escalate_diabetes.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6714ec8cd93dada1b3a7f520d59f7bd0530b4dff
--- /dev/null
+++ b/list/taxonomy/diabetes_management/flows/escalate_diabetes.yaml
@@ -0,0 +1,36 @@
+flow_id: escalate_diabetes
+type: escalation
+domain: diabetes_management
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: diabetes_escalation_notice
+      goal: "Inform patient their care team will be notified about concerning glucose findings"
+      tone: calm_reassuring
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: diabetes_escalation_handoff
+      goal: "Schedule nurse callback for concerning diabetes findings"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/diabetes_management/flows/handoff.yaml b/list/taxonomy/diabetes_management/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..2afc4753391e8d62c47ce27866c0dae3bd899b04
--- /dev/null
+++ b/list/taxonomy/diabetes_management/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: diabetes_management
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: diabetes_management_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: diabetes_management_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/diabetes_management/flows/monitor_diabetes.yaml b/list/taxonomy/diabetes_management/flows/monitor_diabetes.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d040bd3fa835d97455195b3f7274acb0b9b786b7
--- /dev/null
+++ b/list/taxonomy/diabetes_management/flows/monitor_diabetes.yaml
@@ -0,0 +1,65 @@
+flow_id: monitor_diabetes
+type: screening
+domain: diabetes_management
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: diabetes_monitor_step1
+      goal: "Review recent glucose readings and hypoglycemia episodes"
+      tone: warm_professional
+      must_include:
+        - "blood sugar"
+      must_ask:
+        - "What have your blood sugar readings been like recently?"
+        - "Have you had any episodes of low blood sugar?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - glucose_range
+      - hypoglycemia_episodes
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: diabetes_monitor_step2
+      goal: "Check medication adherence and foot care"
+      tone: warm_professional
+      must_include:
+        - "also"
+      must_ask:
+        - "Have you been taking your diabetes medications as prescribed?"
+        - "Have you checked your feet recently for any sores, cuts, or changes?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - medication_adherence
+      - foot_check_status
+
+  - step: 3
+    type: ask
+    response_spec:
+      id: diabetes_monitor_step3
+      goal: "Check eye exam status"
+      tone: warm_professional
+      must_include:
+        - "one more"
+      must_ask:
+        - "When was your last eye exam?"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - eye_exam_status
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_diabetes
+  on_low_risk: reassure_diabetes
+  on_unclear: clarify_diabetes
diff --git a/list/taxonomy/diabetes_management/flows/reassure_diabetes.yaml b/list/taxonomy/diabetes_management/flows/reassure_diabetes.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b8d3888af80139f342ea394f841fc8fe261550e2
--- /dev/null
+++ b/list/taxonomy/diabetes_management/flows/reassure_diabetes.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_diabetes
+type: resolution
+domain: diabetes_management
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: diabetes_reassure
+      goal: "Acknowledge stable diabetes management and reinforce self-care importance"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/diabetes_management/rules.yaml b/list/taxonomy/diabetes_management/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9c0a4fbe2c0354995e4811b963c25352c4a76af1
--- /dev/null
+++ b/list/taxonomy/diabetes_management/rules.yaml
@@ -0,0 +1,21 @@
+domain: diabetes_management
+target_risk_class: R1
+
+decision_rules:
+  - id: diabetes_management_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: monitor_diabetes
+
+  - id: diabetes_management_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: monitor_diabetes
+
+  - id: diabetes_management_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify_diabetes
diff --git a/list/taxonomy/diabetes_management/triggers.yaml b/list/taxonomy/diabetes_management/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..911e4724a709eb172da4e41efb971cc3e05dbb38
--- /dev/null
+++ b/list/taxonomy/diabetes_management/triggers.yaml
@@ -0,0 +1,79 @@
+domain: diabetes_management
+priority: 39
+
+lexical_signals:
+  high:
+    phrases:
+      - "checking on my diabetes management"
+      - "blood sugar monitoring review"
+      - "glucose control check-in"
+      - "A1C review"
+      - "diabetes management check"
+      - "how is my diabetes control"
+      - "diabetes follow-up call"
+      - "blood sugar readings review"
+      - "glucose management update"
+    regex:
+      - "(?:blood sugar|glucose|a1c).{0,20}(?:check|monitor|manage|review)"
+      - "diabetes.{0,20}(?:management|control|check|follow|monitor)"
+  medium:
+    phrases:
+      - "blood sugar has been high"
+      - "sugar is running higher"
+      - "glucose readings are off"
+      - "insulin dose question"
+      - "sugar levels not where they should be"
+      - "blood sugar fluctuating"
+      - "need to adjust my insulin"
+      - "sugar above target"
+      - "A1C went up"
+      - "diabetes is harder to control lately"
+      - "blood sugar keeps going up and down"
+      - "sugar running above normal"
+    regex:
+      - "(?:sugar|glucose).{0,15}(?:high|low|running|been|above|off|fluctuat)"
+      - "insulin.{0,15}(?:dose|adjust|change|question|increase|decrease)"
+      - "(?:a1c|hemoglobin).{0,15}(?:up|went|increase|higher|above)"
+  low:
+    partials:
+      - "diabetes follow-up"
+      - "diabetes appointment"
+      - "diet and diabetes"
+      - "eating and diabetes"
+      - "blood sugar"
+      - "glucose"
+      - "sugar levels"
+      - "A1C"
+      - "insulin"
+      - "diabetes"
+
+negation_handling:
+  patterns:
+    - "blood sugar is normal"
+    - "glucose controlled"
+    - "sugar in range"
+    - "diabetes well managed"
+    - "A1C is good"
+    - "blood sugar stable"
+    - "no issues with sugar"
+    - "diabetes is controlled"
+    - "insulin working well"
+    - "blood sugars have been great"
+    # --- administrative context ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_has_condition: ["E11.*", "E10.*"]
+        patient_on_medication_class: ["insulin"]
+      reason: "Diabetic patient on insulin with management-related language"
+  boost_to_medium:
+    - when:
+        patient_has_condition: ["E11.*", "E10.*"]
+      reason: "Diabetes history raises baseline relevance for management discussions"
diff --git a/list/taxonomy/dka_hhs/flows/clarify.yaml b/list/taxonomy/dka_hhs/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f95d2e9743bcad06399303ba6f889e6c2b389d12
--- /dev/null
+++ b/list/taxonomy/dka_hhs/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: dka_hhs
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: dka_hhs_clarify
+      goal: "Ask patient to describe their dka hhs symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - dka_hhs_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/dka_hhs/flows/escalate_r2.yaml b/list/taxonomy/dka_hhs/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..513e2ab75fc888d65d191237f3347fc4c74db937
--- /dev/null
+++ b/list/taxonomy/dka_hhs/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: dka_hhs
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will be connected to discuss urgent glucose concerns"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "connect"
+        - "important"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: urgent
+    response_spec:
+      id: r2_handoff
+      goal: "Warm transfer to nurse with context summary"
+      tone: professional
+      must_include:
+        - "connecting"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/dka_hhs/flows/escalate_r3.yaml b/list/taxonomy/dka_hhs/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ef8fedb79e5a76e97dc5e6e93fb3c77f80a57294
--- /dev/null
+++ b/list/taxonomy/dka_hhs/flows/escalate_r3.yaml
@@ -0,0 +1,38 @@
+flow_id: escalate_r3
+type: escalation
+domain: dka_hhs
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Inform patient this requires immediate clinical attention and they will
+      be transferred
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/dka_hhs/flows/handoff.yaml b/list/taxonomy/dka_hhs/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..945bd4fb41ab5efb15827bcdabdfff76ee8dc1a1
--- /dev/null
+++ b/list/taxonomy/dka_hhs/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: dka_hhs
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: dka_hhs_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: dka_hhs_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/dka_hhs/flows/reassure_low_risk.yaml b/list/taxonomy/dka_hhs/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6b0cbec00eff664c2a2cef10b1cfeede782d9131
--- /dev/null
+++ b/list/taxonomy/dka_hhs/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: dka_hhs
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: dka_hhs_reassure
+      goal: "Acknowledge the patient's concern about blood sugar, note that their care team will be informed for routine follow-up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/dka_hhs/flows/safety_screen.yaml b/list/taxonomy/dka_hhs/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ebbd2dec08d8e2b007b1c8c6be604141f4ee37cd
--- /dev/null
+++ b/list/taxonomy/dka_hhs/flows/safety_screen.yaml
@@ -0,0 +1,57 @@
+flow_id: safety_screen
+type: screening
+domain: dka_hhs
+
+required_slots:
+  - nausea_vomiting
+  - confusion_status
+  - ketone_symptoms
+  - abdominal_pain
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: dka_hhs_screen_step1
+      goal: "Determine whether the patient is experiencing acute GI symptoms associated with DKA"
+      tone: calm_urgent
+      must_include:
+        - "blood sugar"
+      must_ask:
+        - "Are you experiencing any nausea or vomiting?"
+        - "Any abdominal pain or stomach cramps?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - nausea_vomiting
+      - abdominal_pain
+      - glucose_reading_mg_dl
+      - glucose_level_bucket
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: dka_hhs_screen_step2
+      goal: "Screen for neurological and metabolic danger signals of DKA/HHS"
+      tone: calm_urgent
+      must_include:
+        - "important"
+      must_ask:
+        - "Are you feeling confused or having trouble thinking clearly?"
+        - "Have you noticed any fruity smell on your breath or unusual thirst?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - confusion_status
+      - ketone_symptoms
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_r2: escalate_r2
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_r3
diff --git a/list/taxonomy/dka_hhs/rules.yaml b/list/taxonomy/dka_hhs/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b93b8d833a8f53c121b040035528c3f3c22ebaae
--- /dev/null
+++ b/list/taxonomy/dka_hhs/rules.yaml
@@ -0,0 +1,33 @@
+domain: dka_hhs
+target_risk_class: R3
+
+decision_rules:
+  - id: dka_hhs_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: dka_hhs_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: dka_hhs_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: dka_hhs_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: dka_hhs_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/dka_hhs/triggers.yaml b/list/taxonomy/dka_hhs/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..2e3ec74abb395a8ab0677d4c6461c0f149b419e3
--- /dev/null
+++ b/list/taxonomy/dka_hhs/triggers.yaml
@@ -0,0 +1,181 @@
+domain: dka_hhs
+priority: 86
+
+lexical_signals:
+  high:
+    phrases:
+      - "blood sugar over 500"
+      - "DKA"
+      - "diabetic ketoacidosis"
+      - "vomiting and blood sugar very high"
+      - "confused and sugar is sky high"
+      - "hyperglycemic crisis"
+      - "blood sugar extremely high"
+      - "sugar over 400"
+      - "sugar said HI"
+      - "meter said HI"
+      - "continuous monitor is reading HIGH"
+    regex:
+      - "(DKA|diabetic\\s+ketoacidosis)"
+      - "blood\\s+sugar\\s+(over|above|was|showed|at|read)\\s+[3-9]\\d{2}"
+      - "sugar.{0,40}(sky high|extremely high|over [3-9]\\d{2}|very high|said.{0,3}\\bHI\\b|reading.{0,3}\\bHI\\b|reading.{0,3}\\bHIGH\\b|was\\s+[3-9]\\d{2}|showed\\s+[3-9]\\d{2})"
+      - "(thirst|drink).{0,30}(pee|urinat|bathroom).{0,30}(nause|vomit|sick|confus|foggy)"
+      - "diabetes.{0,80}(confus|foggy|spaced|not\\s+(all there|making sense|thinking)|acting\\s+(weird|off|strange)|blanking|in and out|dozing|talking slow)"
+      - "(confus|foggy|spaced|acting\\s+(weird|off)|not all there|in and out).{0,80}(diabete|sugar|type [12]|insulin)"
+      - "(monitor|meter|glucometer|machine|finger\\s*(poke|prick|stick)|CGM|sensor).{0,30}(\\bHIGH\\b|\\bHI\\b|off the chart|[3-9]\\d{2})"
+      - "(\\bHIGH\\b|\\bHI\\b|[3-9]\\d{2}).{0,30}(monitor|meter|glucometer|machine|finger\\s*(poke|prick|stick)|CGM|sensor)"
+      - "said\\s*[\"']?\\bHI\\b[\"']?"
+      - "(reading|reads|read)\\s*[\"']?(\\bHI\\b|\\bHIGH\\b)[\"']?"
+      - "(sugar|glucose|blood sugar|fingerstick).{0,30}(was|showed|at|read|reads)\\s+[3-9]\\d{2}"
+      - "\\b[3-9]\\d{2}\\s*(mg/dl|mg\\/dl)\\b"
+  medium:
+    phrases:
+      - "sugar over 400 and vomiting"
+      - "diabetic emergency"
+      - "fruity breath and high sugar"
+      - "severe hyperglycemia with vomiting"
+      - "super thirsty and peeing a lot"
+      - "really thirsty and going to the bathroom constantly"
+      - "mouth feels like sandpaper"
+      - "insanely thirsty"
+      - "peeing all the time and thirsty"
+      - "blood sugar won't come down"
+      - "has diabetes and acting weird"
+      - "has diabetes and confused"
+      - "diabetic and throwing up"
+      - "sugar is high and vomiting"
+      - "mouth feels like cotton"
+      - "mouth is like sand"
+      - "it said HI"
+      - "it just said HI"
+      - "said HI on the meter"
+      - "said HI on the machine"
+      - "CGM reading HIGH"
+      - "breath smells sweet"
+      - "breath smells fruity"
+      - "breathing feels heavy"
+      - "not all there and has diabetes"
+    regex:
+      - "(thirst|thirsty|so thirsty|super thirsty).{0,60}(pee|urinat|bathroom|peeing)"
+      - "(pee|urinat|bathroom|peeing).{0,60}(thirst|thirsty)"
+      - "(nause|vomit|threw up|sick).{0,40}(thirst|thirsty|sugar|diabete)"
+      - "(sugar|glucose).{0,40}(high|spike|won'?t come down).{0,40}(vomit|nause|confus|foggy|ketone|fruity|sick|acting weird)"
+      - "(thirsty|thirst).{0,30}(dry mouth|sandpaper|cotton|sand)"
+      - "(diabete|sugar|type [12]|insulin|takes shots).{0,80}(vomit|threw up|throwing up|nause|confus|foggy|spaced|drifting|acting weird|not all there|in and out)"
+      - "(vomit|threw up|throwing up|confus|foggy|spaced|drifting|not all there|in and out).{0,80}(diabete|sugar|type [12]|insulin|takes shots)"
+      - "(breath|breathing).{0,15}(fast|deep|rapid|weird|heavy|hard|labored).{0,40}(diabete|sugar)"
+      - "(breath|mouth).{0,15}(sweet|fruity|nail polish|acetone)"
+      - "(can't keep.{0,10}down|comes back up).{0,50}(diabete|sugar|insulin|type [12])"
+  low:
+    partials:
+      - "ketoacidosis"
+      - "DKA"
+      - "HHS"
+      - "hyperglycemic"
+      - "said HI"
+      - "said HIGH"
+      - "CGM"
+      - "fingerstick"
+
+negation_handling:
+  patterns:
+    - "blood sugar is controlled"
+    - "sugar is normal"
+    - "no DKA symptoms"
+    - "diabetes well controlled"
+    - "sugars have been fine"
+    - "blood sugar is fine"
+    - "sugar a little high"
+    - "sugar a bit high"
+    - "sugar is slightly high"
+    - "glucose out of range"
+    - "blood sugar is a little elevated"
+    - "sugar was high but no other symptoms"
+    - "sugar is up but I feel fine"
+    - "no vomiting"
+    - "no confusion"
+    - "no nausea"
+    - "feeling fine just sugar is up"
+    # --- routine diabetes management context ---
+    - "A1C"
+    - "hemoglobin A1C"
+    - "metformin"
+    - "managing my diabetes"
+    - "diabetes management"
+    - "my doctor told me to check"
+    - "routine glucose check"
+    - "glucose readings"
+    - "blood sugar readings"
+    - "been checking my blood sugar"
+    - "been monitoring"
+    - "adjusting my medication"
+    - "dosing question"
+    - "energy levels are normal"
+    - "feel fine physically"
+    - "readings have been"
+    - "in the 140s"
+    - "in the 150s"
+    - "in the 160s"
+    - "in the 170s"
+    - "in the 180s"
+    # --- additional routine diabetes context ---
+    - "in the 190s"
+    - "in the 200s"
+    - "blood sugar log"
+    - "checking my numbers"
+    - "my endocrinologist"
+    - "diabetes educator"
+    # --- administrative / routine context suppression ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "when can I come in"
+    - "medication refill"
+    - "need a refill"
+    - "routine check"
+    - "just a question"
+    # --- Phase 5: R1 false escalation reduction ---
+    # Routine glucose monitoring
+    - "checking my blood sugar"
+    - "glucose meter reading"
+    - "routine glucose check"
+    - "routine blood sugar check"
+    - "checking my numbers"
+    - "my readings today"
+    - "recording my blood sugar"
+    # Diabetes management context
+    - "managing my diabetes"
+    - "known diabetic"
+    - "diabetes routine"
+    - "diabetes management plan"
+    - "my diabetes is controlled"
+    - "diabetes care"
+    # Insulin / dose adjustment questions
+    - "when should I adjust my insulin"
+    - "dose adjustment question"
+    - "insulin dosing"
+    - "sliding scale question"
+    - "basal rate question"
+    - "bolus question"
+    # Follow-up / administrative context
+    - "A1C follow-up"
+    - "hemoglobin A1C results"
+    - "taking my insulin as prescribed"
+    - "following my diabetes plan"
+    - "endocrinology appointment"
+    - "diabetes check-up"
+    - "appointment timing"
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_has_condition: ["E11.*", "E10.*", "E13.*"]
+        patient_on_medication_class: ["insulin"]
+      reason: "Diabetic on insulin with blood sugar concern"
+    - when:
+        patient_has_condition: ["E11.*", "E10.*"]
+        recent_lab:
+          code: "4548-4"
+          value_above: 9.0
+          within_days: 90
+      reason: "Diabetic with HbA1c above 9 -- elevated DKA risk"
diff --git a/list/taxonomy/domestic_safety_concern/flows/clarify.yaml b/list/taxonomy/domestic_safety_concern/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..bef9a5e66c7105ee65888810e1b6a7281b05aabc
--- /dev/null
+++ b/list/taxonomy/domestic_safety_concern/flows/clarify.yaml
@@ -0,0 +1,27 @@
+flow_id: clarify
+type: clarification
+domain: domestic_safety_concern
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: domestic_safety_clarify
+      goal: "Gently ask the patient to share more about their safety situation"
+      tone: calm_concerned
+      must_include:
+        - "share"
+      must_ask:
+        - "describe"
+      must_not:
+        - "abuse"
+        - "domestic violence"
+        - "fault"
+        - "deserve"
+      max_questions: 1
+    collects:
+      - safety_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/domestic_safety_concern/flows/escalate_r2.yaml b/list/taxonomy/domestic_safety_concern/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..894103f656caaca80382b4da0cf05827702b4557
--- /dev/null
+++ b/list/taxonomy/domestic_safety_concern/flows/escalate_r2.yaml
@@ -0,0 +1,40 @@
+flow_id: escalate_r2
+type: escalation
+domain: domestic_safety_concern
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: domestic_safety_escalate
+      goal: "Inform the patient that a social worker will follow up. Validate their courage in sharing. Do not minimize or judge."
+      tone: calm_reassuring
+      must_include:
+        - "social worker"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "fault"
+        - "deserve"
+        - "why don't you leave"
+        - "police"
+        - "domestic violence"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: social_worker
+    urgency: same_day
+    response_spec:
+      id: domestic_safety_handoff
+      goal: "Schedule same-day social worker callback with safety concern context"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/domestic_safety_concern/flows/safety_screen.yaml b/list/taxonomy/domestic_safety_concern/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..18c7a12e5e5419507e7c9559309d03ba8ad96a72
--- /dev/null
+++ b/list/taxonomy/domestic_safety_concern/flows/safety_screen.yaml
@@ -0,0 +1,57 @@
+flow_id: safety_screen
+type: screening
+domain: domestic_safety_concern
+
+required_slots:
+  - harm_type
+  - immediate_danger
+  - safe_to_talk
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: domestic_safety_screen_step1
+      goal: "First assess whether the patient is safe to talk right now and whether they are in immediate danger"
+      tone: calm_concerned
+      must_include:
+        - "safe"
+      must_ask:
+        - "Are you in a safe place to talk right now?"
+        - "Are you in immediate danger?"
+      must_not:
+        - "police"
+        - "domestic violence"
+        - "abuse"
+        - "fault"
+        - "deserve"
+      max_questions: 2
+    collects:
+      - safe_to_talk
+      - immediate_danger
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: domestic_safety_screen_step2
+      goal: "Understand the nature of the safety concern without pushing for details"
+      tone: calm_concerned
+      must_include:
+        - "help"
+      must_ask:
+        - "Can you tell me a little about what is happening?"
+      must_not:
+        - "fault"
+        - "deserve"
+        - "why don't you leave"
+        - "police"
+      max_questions: 1
+    collects:
+      - harm_type
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_r3: escalate_r2
+  on_low_risk: escalate_r2
+  on_unclear: escalate_r2
diff --git a/list/taxonomy/domestic_safety_concern/flows/warm_transfer_social_work.yaml b/list/taxonomy/domestic_safety_concern/flows/warm_transfer_social_work.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..79ecf78a286453208bf5eb5d1199100f04ffb2fc
--- /dev/null
+++ b/list/taxonomy/domestic_safety_concern/flows/warm_transfer_social_work.yaml
@@ -0,0 +1,23 @@
+flow_id: warm_transfer_social_work
+type: resolution
+domain: domestic_safety_concern
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: domestic_safety_social_work_referral
+      goal: "Inform the patient their care team includes people who can help with safety concerns and connect them with resources"
+      tone: warm_empathetic
+      must_include:
+        - "care team"
+        - "resources"
+        - "help"
+      must_not:
+        - "fault"
+        - "deserve"
+        - "victim"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/domestic_safety_concern/rules.yaml b/list/taxonomy/domestic_safety_concern/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..58e9dd1e01dbe3d77de6c28352d2d20961c8b03f
--- /dev/null
+++ b/list/taxonomy/domestic_safety_concern/rules.yaml
@@ -0,0 +1,33 @@
+domain: domestic_safety_concern
+target_risk_class: R2
+
+decision_rules:
+  - id: domestic_safety_concern_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: domestic_safety_concern_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: domestic_safety_concern_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: domestic_safety_concern_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r2
+
+  - id: domestic_safety_concern_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/domestic_safety_concern/triggers.yaml b/list/taxonomy/domestic_safety_concern/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..24d5414e3a84b993b27e16d12f2942f539d6c747
--- /dev/null
+++ b/list/taxonomy/domestic_safety_concern/triggers.yaml
@@ -0,0 +1,88 @@
+domain: domestic_safety_concern
+priority: 72
+
+lexical_signals:
+  high:
+    phrases:
+      - "not safe at home"
+      - "he hits me"
+      - "she hits me"
+      - "afraid of my partner"
+      - "being hurt at home"
+      - "locked in the house"
+      - "can't leave the house"
+      - "threatens me"
+      - "scared of my husband"
+      - "scared of my wife"
+      - "he won't let me leave"
+      - "she won't let me leave"
+      - "being abused"
+      - "elder abuse"
+      - "someone is hurting me"
+      - "hit me last night"
+      - "chokes me"
+      - "afraid to go home"
+      - "my partner hurts me"
+      - "beaten by my spouse"
+      - "they take my money"
+      - "won't let me see the doctor"
+      - "controls everything I do"
+      - "threatened to kill me"
+      - "afraid for my life at home"
+      - "bruises from being hit"
+    regex:
+      - "(not|don't\\s+feel|never)\\s+safe.{0,15}(at\\s+home|here|in\\s+my\\s+house|with\\s+him|with\\s+her)"
+      - "(he|she|my\\s+partner|my\\s+husband|my\\s+wife|my\\s+spouse|they).{0,15}(hit|hits|beat|beats|hurt|hurts|choke|chokes|threaten|threatens|abuse|abuses)\\s+me"
+      - "(afraid|scared|terrified|frightened).{0,15}(of|to\\s+go\\s+home|my\\s+partner|my\\s+husband|my\\s+wife|my\\s+spouse)"
+      - "(can't|cannot|won't\\s+let\\s+me)\\s+(leave|go\\s+out|see\\s+the\\s+doctor|call|get\\s+help)"
+      - "(locked|trapped|stuck).{0,10}(in|at).{0,10}(house|home|room)"
+      - "(elder|being).{0,10}(abuse|abused|neglected|mistreated)"
+      - "(take|takes|took|control).{0,15}(my\\s+money|my\\s+medication|everything)"
+  medium:
+    phrases:
+      - "don't feel safe"
+      - "afraid at home"
+      - "partner is aggressive"
+      - "yells at me all the time"
+      - "pushed me"
+      - "grabbed me"
+      - "afraid of someone at home"
+      - "home situation is bad"
+      - "being mistreated"
+      - "someone takes advantage of me"
+      - "no control over my life"
+      - "not allowed to go out"
+      - "treated badly at home"
+    regex:
+      - "(don't|do\\s+not)\\s+feel\\s+safe"
+      - "(afraid|scared).{0,10}(at\\s+home|of\\s+someone)"
+      - "(push|grab|shove|yell|scream).{0,10}(at|ed)\\s+me"
+      - "(mistreat|neglect|take\\s+advantage).{0,10}(me|of\\s+me)"
+  low:
+    partials:
+      - "not safe"
+      - "afraid at home"
+      - "abuse"
+      - "hurt by someone"
+      - "domestic"
+
+negation_handling:
+  patterns:
+    - "i feel safe at home"
+    - "i am safe at home"
+    - "i'm safe at home"
+    - "no safety concerns"
+    - "home is fine"
+    - "everything is okay at home"
+    - "safe environment"
+    - "good relationship"
+    - "partner is supportive"
+    - "not afraid"
+    - "i feel safe"
+    - "comfortable at home"
+    - "no one is hurting me"
+    - "not being abused"
+    - "no abuse"
+    - "home situation is good"
+    - "happy at home"
+  action: downgrade_confidence
diff --git a/list/taxonomy/dvt_education/flows/dvt_anticoagulation_education.yaml b/list/taxonomy/dvt_education/flows/dvt_anticoagulation_education.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b1bb106b73d63803ef74674ffe95969c15589106
--- /dev/null
+++ b/list/taxonomy/dvt_education/flows/dvt_anticoagulation_education.yaml
@@ -0,0 +1,49 @@
+flow_id: dvt_anticoagulation_education
+type: ask
+domain: dvt_education
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: dvt_anticoag_overview
+      goal: "Explain that warfarin slows the body's clotting process to prevent new clots and keep existing clots from growing, that most people with a provoked DVT take it for 3-6 months, and ask what the patient knows about taking it"
+      tone: warm_professional
+      must_include:
+        - "warfarin"
+        - "blood thinner"
+        - "prevent"
+      must_ask:
+        - "what do you know about how to take your blood thinner"
+      must_not:
+        - "diagnos"
+        - "change your medications"
+        - "adjust"
+        - "prescribe"
+        - "call 911"
+        - "emergency"
+      max_questions: 1
+    collects:
+      - warfarin_knowledge
+
+  - step: 2
+    type: respond
+    response_spec:
+      id: dvt_anticoag_key_points
+      goal: "Reinforce key warfarin points: take at the same time each day, do not skip doses, INR blood tests measure clotting time with a target range of 2-3, vitamin K foods and other medications can interact with warfarin so keep intake consistent and report changes to care team"
+      tone: warm_supportive
+      must_include:
+        - "same time each day"
+        - "INR"
+        - "two"
+        - "three"
+        - "lab"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "change your medications"
+        - "adjust"
+        - "prescribe"
+        - "call 911"
+        - "emergency"
+      max_questions: 1
diff --git a/list/taxonomy/dvt_education/flows/dvt_bleeding_precautions.yaml b/list/taxonomy/dvt_education/flows/dvt_bleeding_precautions.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d1fb1a8cb33a79ea6d9c186b7b4695c4c0585e38
--- /dev/null
+++ b/list/taxonomy/dvt_education/flows/dvt_bleeding_precautions.yaml
@@ -0,0 +1,51 @@
+flow_id: dvt_bleeding_precautions
+type: ask
+domain: dvt_education
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: dvt_bleeding_overview
+      goal: "Explain that blood thinners carry a small but real increased bleeding risk (about 1-3 per 100 patients per year for major bleeding), and ask the patient what precautions they are aware of"
+      tone: warm_professional
+      must_include:
+        - "bleeding"
+        - "blood thinner"
+        - "precaution"
+      must_ask:
+        - "what precautions have you heard about while taking a blood thinner"
+      must_not:
+        - "diagnos"
+        - "change your medications"
+        - "adjust"
+        - "prescribe"
+        - "call 911"
+        - "emergency"
+      max_questions: 1
+    collects:
+      - bleeding_precaution_knowledge
+
+  - step: 2
+    type: respond
+    response_spec:
+      id: dvt_bleeding_key_points
+      goal: "Reinforce bleeding precautions: soft toothbrush, electric razor, careful with injury-prone activities, apply firm pressure to cuts. Cover warning signs requiring care team contact: unusual bruising, dark or tarry stools, blood in urine, bleeding that will not stop, coughing up blood. Cover PE warning signs requiring emergency care: sudden shortness of breath, chest pain, fast heartbeat"
+      tone: warm_supportive
+      must_include:
+        - "soft toothbrush"
+        - "electric razor"
+        - "bruising"
+        - "dark"
+        - "stool"
+        - "shortness of breath"
+        - "chest pain"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "change your medications"
+        - "adjust"
+        - "prescribe"
+        - "call 911"
+        - "emergency"
+      max_questions: 1
diff --git a/list/taxonomy/dvt_education/flows/dvt_diagnosis_teachback.yaml b/list/taxonomy/dvt_education/flows/dvt_diagnosis_teachback.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6fd6369a48dcac89ff1438e6d694528154607e5d
--- /dev/null
+++ b/list/taxonomy/dvt_education/flows/dvt_diagnosis_teachback.yaml
@@ -0,0 +1,51 @@
+flow_id: dvt_diagnosis_teachback
+type: ask
+domain: dvt_education
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: dvt_diagnosis_teachback
+      goal: "Teach-back: ask the patient what they understand about their blood clot (DVT) and why it needs treatment"
+      tone: warm_curious
+      must_include:
+        - "own words"
+        - "blood clot"
+      must_ask:
+        - "what do you understand about your blood clot"
+      must_not:
+        - "diagnos"
+        - "change your medications"
+        - "adjust"
+        - "prescribe"
+        - "call 911"
+        - "emergency"
+        - "wrong"
+        - "incorrect"
+      max_questions: 1
+    collects:
+      - dvt_understanding
+
+  - step: 2
+    type: respond
+    response_spec:
+      id: dvt_teachback_reinforce
+      goal: "Reinforce correct understanding and gently fill gaps: DVT is a clot in a deep vein usually in the leg, the main danger is a piece breaking off and traveling to the lungs (pulmonary embolism), and treatment with a blood thinner prevents clot growth and new clots"
+      tone: warm_supportive
+      must_include:
+        - "deep vein"
+        - "leg"
+        - "lung"
+        - "treatment"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "change your medications"
+        - "adjust"
+        - "prescribe"
+        - "call 911"
+        - "emergency"
+        - "wrong"
+        - "incorrect"
+      max_questions: 1
diff --git a/list/taxonomy/dvt_education/flows/edu_final_summary_dvt.yaml b/list/taxonomy/dvt_education/flows/edu_final_summary_dvt.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7da7dfb87135a0f3bf08bc01639b9e0709789a69
--- /dev/null
+++ b/list/taxonomy/dvt_education/flows/edu_final_summary_dvt.yaml
@@ -0,0 +1,27 @@
+flow_id: edu_final_summary_dvt
+type: respond
+domain: dvt_education
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: dvt_final_summary
+      goal: "Summarize key takeaways: DVT is a clot in a deep vein that needs treatment to prevent PE, take warfarin at the same time daily and keep INR in target range of 2-3, follow bleeding precautions and watch for warning signs (bruising, dark stools, blood in urine), and seek emergency care for sudden shortness of breath or chest pain. Thank the patient and close warmly"
+      tone: warm_professional
+      must_include:
+        - "blood clot"
+        - "warfarin"
+        - "INR"
+        - "bleeding precaution"
+        - "shortness of breath"
+        - "thank you"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "change your medications"
+        - "adjust"
+        - "prescribe"
+        - "call 911"
+        - "emergency"
+      max_questions: 0
diff --git a/list/taxonomy/dvt_education/flows/edu_intro_dvt.yaml b/list/taxonomy/dvt_education/flows/edu_intro_dvt.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9795b41db758af95bc9ff66474f2676940c52a57
--- /dev/null
+++ b/list/taxonomy/dvt_education/flows/edu_intro_dvt.yaml
@@ -0,0 +1,27 @@
+flow_id: edu_intro_dvt
+type: ask
+domain: dvt_education
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: dvt_edu_intro
+      goal: "Introduce yourself and explain this is an education call about DVT and blood thinner safety"
+      tone: warm_professional
+      must_include:
+        - "education call"
+        - "blood clot"
+        - "blood thinner"
+      must_ask:
+        - "walk through some important information together"
+      must_not:
+        - "diagnos"
+        - "change your medications"
+        - "adjust"
+        - "prescribe"
+        - "call 911"
+        - "emergency"
+      max_questions: 1
+    collects:
+      - edu_consent
diff --git a/list/taxonomy/dvt_education/rules.yaml b/list/taxonomy/dvt_education/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..efd2ac8c217e21a8c437afac19eec1f9dad912f4
--- /dev/null
+++ b/list/taxonomy/dvt_education/rules.yaml
@@ -0,0 +1,32 @@
+domain: dvt_education
+
+decision_rules:
+  - id: dvt_edu_intro
+    if:
+      agenda_step: edu_intro
+    then:
+      flow: edu_intro_dvt
+
+  - id: dvt_diagnosis_understanding
+    if:
+      agenda_step: diagnosis_understanding
+    then:
+      flow: dvt_diagnosis_teachback
+
+  - id: dvt_anticoagulation_therapy
+    if:
+      agenda_step: anticoagulation_therapy
+    then:
+      flow: dvt_anticoagulation_education
+
+  - id: dvt_bleeding_precautions
+    if:
+      agenda_step: bleeding_precautions
+    then:
+      flow: dvt_bleeding_precautions
+
+  - id: dvt_summary_note
+    if:
+      agenda_step: summary_note
+    then:
+      flow: edu_final_summary_dvt
diff --git a/list/taxonomy/dvt_education/triggers.yaml b/list/taxonomy/dvt_education/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e8aa4fe37bb56cfeaf58bb2ee241e2bc3f1f5024
--- /dev/null
+++ b/list/taxonomy/dvt_education/triggers.yaml
@@ -0,0 +1,8 @@
+domain: dvt_education
+priority: 0
+
+# Empty signals — this domain is agenda-driven, not nomination-driven.
+# It becomes the default control path for DVT education calls after
+# consent completes. The engine activates it by setting agenda_step,
+# not through lexical nomination.
+lexical_signals: {}
diff --git a/list/taxonomy/dvt_signal/flows/clarify.yaml b/list/taxonomy/dvt_signal/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..68199881645075db140ca8a87696b40d09ae3334
--- /dev/null
+++ b/list/taxonomy/dvt_signal/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: dvt_signal
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: dvt_signal_clarify
+      goal: "Ask patient to describe their dvt signal symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - dvt_signal_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/dvt_signal/flows/escalate_r2.yaml b/list/taxonomy/dvt_signal/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c352f85b380cbea46ffbaeda886c1c619de2b4ab
--- /dev/null
+++ b/list/taxonomy/dvt_signal/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: dvt_signal
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/dvt_signal/flows/handoff.yaml b/list/taxonomy/dvt_signal/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..34d35285a9723b14236f3fe5c9fda953410e241f
--- /dev/null
+++ b/list/taxonomy/dvt_signal/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: dvt_signal
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: dvt_signal_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: dvt_signal_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/dvt_signal/flows/reassure_low_risk.yaml b/list/taxonomy/dvt_signal/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6f169fcc5a9b2d8b3f9a76dd8147e790e12030da
--- /dev/null
+++ b/list/taxonomy/dvt_signal/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: dvt_signal
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: dvt_signal_reassure
+      goal: "Acknowledge the patient's concern about leg symptoms, note that their care team will be informed for routine follow-up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/dvt_signal/flows/safety_screen.yaml b/list/taxonomy/dvt_signal/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..61815e0e6eddfb7039c25650b0c5df92e2118eaf
--- /dev/null
+++ b/list/taxonomy/dvt_signal/flows/safety_screen.yaml
@@ -0,0 +1,54 @@
+flow_id: safety_screen
+type: screening
+domain: dvt_signal
+
+required_slots:
+  - leg_swelling_acute
+  - calf_tenderness
+  - immobility_history
+  - leg_warmth_redness
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: dvt_signal_screen_step1
+      goal: "Determine whether leg swelling is acute and unilateral"
+      tone: calm_urgent
+      must_include:
+        - "leg"
+      must_ask:
+        - "Is the swelling in one leg only, and did it come on recently?"
+        - "Is your calf tender or painful when you touch it or walk?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - leg_swelling_acute
+      - calf_tenderness
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: dvt_signal_screen_step2
+      goal: "Screen for DVT risk factors and additional signs"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "Have you been sitting or lying still for long periods recently — like a long trip or bed rest?"
+        - "Is the affected leg warm to the touch or red?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - immobility_history
+      - leg_warmth_redness
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_r2
diff --git a/list/taxonomy/dvt_signal/rules.yaml b/list/taxonomy/dvt_signal/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f219c87e7f3ff1a813be7c29791ad818b3688863
--- /dev/null
+++ b/list/taxonomy/dvt_signal/rules.yaml
@@ -0,0 +1,27 @@
+domain: dvt_signal
+target_risk_class: R2
+
+decision_rules:
+  - id: dvt_signal_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: dvt_signal_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: dvt_signal_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: dvt_signal_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/dvt_signal/triggers.yaml b/list/taxonomy/dvt_signal/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d06ca7c0a33a12239e3ae7fd443fe04a36f7b181
--- /dev/null
+++ b/list/taxonomy/dvt_signal/triggers.yaml
@@ -0,0 +1,300 @@
+domain: dvt_signal
+priority: 77
+
+lexical_signals:
+  high:
+    phrases:
+      - "leg is swollen and painful"
+      - "DVT"
+      - "deep vein thrombosis"
+      - "calf is red and swollen"
+      - "unilateral leg swelling"
+      - "left calf is swollen and tight"
+      - "calf looks puffy and feels weird"
+      - "one of my legs feels bigger"
+      - "one leg is swollen and the other is normal"
+      - "my left leg is twice the size of my right"
+      - "calf is hard and swollen on one side"
+      - "leg swelled up after my surgery"
+      - "one leg is red hot and swollen"
+      - "blood clot in my leg"
+      - "doctor said it might be a clot"
+      - "calf is painful and swollen since my flight"
+      - "one ankle is hugely swollen"
+      - "leg suddenly swelled up overnight"
+      - "whole leg from thigh to ankle is swollen"
+      - "positive Homans sign"
+      - "calf pain with dorsiflexion"
+      - "my leg blew up after being on bed rest"
+      - "leg has been swollen and warm for two days"
+    regex:
+      - "(DVT|deep\\s+vein\\s+thrombosis)"
+      - "(one|unilateral|left|right)\\s+(leg|calf)\\s+(swell|is\\s+swoll|looks?\\s+puff)"
+      - "(calf|leg).*(swollen|puffy|tight|thicker).*(one|asymmetric|other)"
+      - "one\\s+leg\\s+much\\s+bigger\\s+than\\s+the\\s+other"
+      - "pant\\s+leg\\s+(is\\s+)?tight"
+      - "blood\\s+clot.*(leg|calf)"
+      - "(leg|calf).*(blood\\s+clot)"
+      - "(leg|calf).*(twice|double|way\\s+bigger).*than.*(other|right|left)"
+      - "(leg|calf).*(suddenly|overnight|woke\\s+up).*(swell|swoll|puff|big)"
+      - "(suddenly|overnight|woke\\s+up).*(leg|calf).*(swell|swoll|puff|big)"
+      - "(surgery|procedure|bed\\s+rest|immobil|cast).*(leg|calf).*(swell|swoll)"
+      - "(leg|calf).*(swell|swoll).*(surgery|procedure|bed\\s+rest|flight|travel)"
+      - "Homans"
+      - "(whole|entire)\\s+(leg|calf).*(swell|swoll|puff|big)"
+      - "(leg|calf).*(hard|firm|taut).*(swell|swoll)"
+  medium:
+    phrases:
+      - "leg swelling getting worse"
+      - "calf pain and swelling"
+      - "one leg is swollen"
+      - "leg pain and warmth"
+      - "swollen leg since surgery"
+      - "asymmetric leg swelling"
+      - "calf looks noticeably thicker"
+      - "ankle looks a little puffy"
+      - "left calf looks puffy"
+      - "leg feels kind of off"
+      - "comparing them in the mirror"
+      - "definitely asymmetric"
+      - "clot risks after long flights"
+      - "his calf hurts bad"
+      - "my sock is leaving a deeper mark on one leg"
+      - "shoe feels tighter on one foot"
+      - "leg aches and feels heavy"
+      - "calf is sore and warm to the touch"
+      - "my leg has been swollen for a few days"
+      - "pitting edema in one leg"
+      - "one ankle is puffier than the other"
+      - "leg feels heavy and tight"
+      - "been sitting a lot and now my leg hurts"
+      - "calf cramp that won't go away"
+      - "leg pain worse when I walk"
+      - "swelling that started after the long drive"
+      - "my calf has a deep ache"
+      - "leg is discolored and swollen"
+      - "pain behind my knee and calf is swollen"
+      - "thigh feels tight and swollen"
+      - "leg swelling not going down with elevation"
+      # --- Phase 6: R2 recall expansion ---
+      - "leg is swollen and red"
+      - "calf is tender and warm"
+      - "one leg bigger than the other"
+      - "leg pain after sitting"
+      - "swelling won't go down"
+      # --- Phase 7: Classic DVT triad ---
+      - "leg swelling"
+      - "swelling in my leg"
+      - "swelling in my left leg"
+      - "swelling in my right leg"
+      - "calf pain"
+      - "calf is painful"
+      - "calf is sore"
+      - "calf is tender"
+      - "warmth in leg"
+      - "warmth in my leg"
+      - "leg feels warm"
+      - "leg is warm"
+      - "calf feels warm"
+      - "calf is warm"
+      - "leg looks puffy"
+      - "lower leg looks puffy"
+      - "calf looks puffy"
+      - "ankle looks puffy"
+      # --- Phase 7: Risk factor context ---
+      - "after surgery and leg swelling"
+      - "long flight and leg pain"
+      - "long flight and leg swelling"
+      - "after the flight my leg"
+      - "since the flight my leg"
+      - "drove for hours"
+      - "drove for hours and didn't stop"
+      - "drove and didn't stop much"
+      - "sat for hours"
+      - "sat for hours at a time"
+      - "sitting for a long time"
+      - "been sitting a lot"
+      - "planted in the chair"
+      - "didn't get up much"
+      - "pinned in my seat"
+      - "pinned in the window seat"
+      # --- Phase 7: Asymmetry ---
+      - "one leg bigger"
+      - "one leg is bigger"
+      - "one leg bigger than other"
+      - "one leg bigger than the other"
+      - "swelling just in one leg"
+      - "swelling in one leg only"
+      - "only the left leg"
+      - "only the right leg"
+      - "just the left leg"
+      - "just the right leg"
+      - "other leg is normal"
+      - "other leg is totally normal"
+      - "right leg is totally normal"
+      - "left leg is totally normal"
+      - "one side only"
+      - "sock tighter on one side"
+      - "sock is tighter on one side"
+      - "sock line deeper on one side"
+      - "pant leg feels snug"
+      - "pant leg feels tight"
+      # --- Phase 7: Color changes ---
+      - "leg looks red"
+      - "leg is red"
+      - "calf looks red"
+      - "calf is red"
+      - "discoloration in leg"
+      - "discoloration in calf"
+      - "slight discoloration"
+      - "leg is discolored"
+      - "calf is discolored"
+      - "leg looks flushed"
+      - "calf looks flushed"
+      - "more flushed than usual"
+      - "slightly more pink"
+      - "faint pinkish area"
+      - "mild redness"
+      - "slightly darker"
+      - "temperature difference"
+    regex:
+      - "(calf|leg).*(puffy|swollen|thick|warm|tight|bigger)"
+      - "(noticed|something).*(off|wrong|weird).*\\b(leg|calf)\\b"
+      - "\\b(leg|calf)\\b.*(off|wrong|weird|bigger|different)"
+      - "(after|since|from)\\s+(long\\s+)?(flight|sitting|travel|surgery|car)"
+      - "clot\\s+(risk|worry|scare)"
+      - "something\\s+(off|wrong|weird).*\\bleg\\b"
+      - "something\\s+with\\s+(his|her|my)\\s+leg"
+      - "(calf|leg)\\s+hurts?\\s+(bad|a\\s+lot)"
+      - "(calf|leg).*(cramp|pain).*won't\\s+quit"
+      - "leg.*(pain|limp|hurt).*([78])\\s*(out\\s+of|/)"
+      - "body\\s+feels\\s+off"
+      - "(sitting|sat)\\s+a\\s+lot"
+      - "leg\\s+thing"
+      - "sock.*(mark|indent|impression).*(one|left|right)\\s+(leg|ankle)"
+      - "shoe.*(tight|snug).*(one|left|right)\\s+(foot|ankle)"
+      - "(leg|calf).*(ache|heavy|tight|sore).*(warm|hot)"
+      - "(leg|calf).*(swell|swoll|puff).*few\\s+days"
+      - "pitting\\s+edema"
+      - "(leg|calf).*(discolor|purpl|bluish|reddish)"
+      - "behind\\s+(my\\s+)?knee.*(pain|sore|ache|swell)"
+      - "(thigh|upper\\s+leg).*(tight|swell|swoll|pain)"
+      - "(leg|calf).*(swell|swoll).*(not|won't|doesn't).*(go\\s+down|improv|better)"
+      - "(elevation|elevat|prop).*(not|doesn't|won't).*(help|work|reduc)"
+      - "(long\\s+)?(drive|road\\s+trip|car\\s+ride).*(leg|calf).*(swell|pain|ache)"
+      - "(leg|calf).*(deep\\s+ache|deep\\s+pain|dull\\s+ache)"
+      # --- Phase 6: R2 recall expansion ---
+      - "(leg|calf|thigh).{0,20}(swollen|swelling|bigger).{0,20}(red|warm|tender|painful)"
+      - "one.{0,10}(leg|calf).{0,20}(bigger|larger|more swollen).{0,15}(than|other)"
+      - "(after|from).{0,15}(sitting|flight|travel|driving).{0,20}(leg|calf).{0,15}(swell|pain|hurt)"
+      - "(swelling|pain).{0,15}(won't|doesn't|not).{0,10}(go down|improve|better)"
+      # --- Phase 7: Classic triad regex ---
+      - "(leg|calf|ankle).{0,15}(swelling|swollen|puffy|puffiness)"
+      - "(calf|leg).{0,15}(pain|painful|sore|tender|tenderness)"
+      - "(leg|calf).{0,15}(feels?|is).{0,10}(warm|warmer|hot)"
+      - "(warmth|warm).{0,15}(in|on).{0,10}(the\\s+)?(leg|calf)"
+      # --- Phase 7: Risk factor context regex ---
+      - "(after|since|from).{0,15}(the\\s+)?flight.{0,15}(my\\s+)?(leg|calf)"
+      - "(drove|driving|drive).{0,20}(hours|long\\s+time|didn'?t\\s+stop)"
+      - "(sat|sitting|been\\s+sitting).{0,15}(for\\s+)?(hours|long\\s+time|a\\s+lot)"
+      - "(planted|stuck|pinned).{0,15}(in|at).{0,15}(chair|seat|desk)"
+      - "(didn'?t|don'?t).{0,10}(get\\s+up|move).{0,10}(much|often)"
+      # --- Phase 7: Asymmetry regex ---
+      - "one.{0,10}(leg|calf).{0,10}(is\\s+)?(bigger|larger|more\\s+swollen)"
+      - "(just|only).{0,10}(the\\s+)?(left|right).{0,10}(leg|calf)"
+      - "(other|opposite).{0,10}(leg|calf).{0,10}(is\\s+)?(normal|fine|okay)"
+      - "sock.{0,15}(tighter|deeper|mark|line).{0,15}(on\\s+)?one.{0,10}(side|leg)"
+      - "pant.{0,10}leg.{0,10}(feels?|is).{0,10}(snug|tight)"
+      # --- Phase 7: Color changes regex ---
+      - "(leg|calf).{0,15}(looks?|is).{0,10}(red|reddish|pink|pinkish|flushed)"
+      - "(discoloration|discolored).{0,15}(in|on|of).{0,15}(the\\s+)?(leg|calf)"
+      - "(slight|mild|faint).{0,10}(discoloration|redness|pinkish)"
+      - "(slightly|more).{0,10}(darker|pink|flushed).{0,10}(than|area)"
+      - "temperature.{0,10}difference"
+  low:
+    partials:
+      - "leg swelling"
+      - "calf pain"
+      - "DVT"
+      - "thrombosis"
+      - "leg puffy"
+      - "calf swollen"
+      - "calf tight"
+      - "leg bigger"
+      - "blood clot"
+      - "leg feels off"
+      - "calf hurts"
+      - "leg hurts"
+      - "limping"
+      - "leg heavy"
+      - "calf ache"
+      - "ankle puffy"
+      - "leg discolored"
+      - "leg warm"
+      - "pitting edema"
+      - "leg not improving"
+      - "sock mark"
+      - "calf cramping"
+      - "behind knee pain"
+
+negation_handling:
+  patterns:
+    - "no leg swelling"
+    - "legs are fine"
+    - "swelling went down"
+    - "both legs same"
+    - "legs look normal"
+    - "no DVT"
+    - "DVT was ruled out"
+    - "ultrasound was negative"
+    - "no blood clot"
+    - "clot was ruled out"
+    - "legs are equal size"
+    - "swelling resolved"
+    - "leg is back to normal"
+    - "no calf tenderness"
+    - "both calves the same"
+    - "leg swelling improved"
+    - "no pain in the calf"
+    - "legs are symmetric"
+    - "doppler was negative"
+    - "no evidence of clot"
+    - "swelling going down with elevation"
+    - "leg looks normal now"
+    - "calf pain resolved"
+    # --- post-procedure/incontinence context (R1 scenarios) ---
+    - "bladder surgery"
+    - "prostate surgery"
+    - "prostate procedure"
+    - "TURP"
+    - "hysterectomy"
+    - "bladder control"
+    - "incontinence"
+    - "incontinence since surgery"
+    - "urine leakage since surgery"
+    - "leaking urine"
+    - "urine leakage"
+    - "pelvic floor"
+    - "wearing pads"
+    - "urological"
+    - "urology"
+    - "catheter removal"
+    - "catheter out"
+    - "after the catheter"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_on_medication_class: ["anticoagulants"]
+      reason: "On anticoagulation suggests known VTE risk"
+    - when:
+        patient_has_condition: ["Z86.71*"]
+      reason: "History of VTE increases recurrence risk"
diff --git a/list/taxonomy/ectopic_signal/flows/clarify.yaml b/list/taxonomy/ectopic_signal/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8eb26e40f581008a33ac6dc9e23945fa5e2f1ddd
--- /dev/null
+++ b/list/taxonomy/ectopic_signal/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: ectopic_signal
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: ectopic_signal_clarify
+      goal: "Ask patient to describe their ectopic signal symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - ectopic_signal_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/ectopic_signal/flows/escalate_r2.yaml b/list/taxonomy/ectopic_signal/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ce5169b92528ba5519f2b04493b23f1c6e3c49e6
--- /dev/null
+++ b/list/taxonomy/ectopic_signal/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: ectopic_signal
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/ectopic_signal/flows/handoff.yaml b/list/taxonomy/ectopic_signal/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d9ce65789816ddb610791bbd58555714a4d02f52
--- /dev/null
+++ b/list/taxonomy/ectopic_signal/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: ectopic_signal
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: ectopic_signal_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: ectopic_signal_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/ectopic_signal/flows/safety_screen.yaml b/list/taxonomy/ectopic_signal/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3db78886126e83a37ec29ef8a24c4de95ff7fee8
--- /dev/null
+++ b/list/taxonomy/ectopic_signal/flows/safety_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: safety_screen
+type: screening
+domain: ectopic_signal
+
+required_slots:
+  - pain_location
+  - bleeding_status
+  - pregnancy_status
+  - pain_severity
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "pain location"
+        - "bleeding status"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - pain_location
+      - bleeding_status
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "pregnancy status"
+        - "pain severity"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - pregnancy_status
+      - pain_severity
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/list/taxonomy/ectopic_signal/rules.yaml b/list/taxonomy/ectopic_signal/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..2266904a4e31f8a014c1d14c22ed35081d6cdcbd
--- /dev/null
+++ b/list/taxonomy/ectopic_signal/rules.yaml
@@ -0,0 +1,27 @@
+domain: ectopic_signal
+target_risk_class: R2
+
+decision_rules:
+  - id: ectopic_signal_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: ectopic_signal_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: ectopic_signal_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: ectopic_signal_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/ectopic_signal/triggers.yaml b/list/taxonomy/ectopic_signal/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3ad5dafef62f1bd11c43a8caebc62650de167c1f
--- /dev/null
+++ b/list/taxonomy/ectopic_signal/triggers.yaml
@@ -0,0 +1,160 @@
+domain: ectopic_signal
+priority: 71
+
+lexical_signals:
+  high:
+    phrases:
+      - 'pregnant with severe abdominal pain'
+      - 'sharp pain on one side and pregnant'
+      - 'possible ectopic pregnancy'
+      - 'pregnant and sharp pelvic pain'
+      - 'lower abdominal pain and could be pregnant'
+      - 'sharp pain low on the right side of my pelvis'
+      - 'one-sided pain and spotting'
+      - 'pregnant and spotting with pain'
+      - 'positive home test and pain'
+      - 'pregnant and bleeding with sharp pain'
+      - 'shoulder tip pain and pregnant'
+      - 'stabbing pain in my pelvis and positive pregnancy test'
+      - 'six weeks pregnant with one-sided pain'
+      - 'just found out I am pregnant and have terrible pain on one side'
+      - 'sharp pain right above my hip and I missed my period'
+      - 'excruciating one-sided pain and vaginal bleeding'
+      - 'collapsed from pain and I am early pregnant'
+      - 'pregnant and pain is shooting to my shoulder'
+      - 'positive test this morning and now sharp lower pain'
+      - 'IVF pregnancy with sudden pelvic pain'
+    regex:
+      - 'pregnant.*(abdominal|pelvic|belly|stomach)\s+pain'
+      - 'ectopic\s+pregnancy'
+      - '(sharp|stabbing)\s+pain.*(one[- ]?sided|right side|left side).*(pelv|abdomen|belly)'
+      - '(spotting|bleeding).*(pregnant|positive\s+test)'
+      - 'pregnant.*(spotting|bleeding).*(pain|cramp)'
+      - '\d+\s+weeks?\s+pregnant.*(pain|bleed|spot)'
+      - '(positive\s+(home\s+)?test|missed\s+(my\s+)?period).{0,30}(sharp|stab|severe).{0,15}pain'
+      - '(sharp|stab|severe).{0,15}pain.{0,30}(positive\s+test|missed\s+(my\s+)?period|pregnant)'
+      - 'shoulder\s+(tip\s+)?pain.{0,25}(pregnant|positive\s+test|early\s+pregnancy|bleeding)'
+      - '(pregnant|early\s+pregnancy).{0,25}shoulder\s+(tip\s+)?pain'
+      - '(collapsed|fainted|passed\s+out).{0,25}(pregnant|early\s+pregnancy|positive\s+test)'
+      - '(IVF|fertility\s+treatment).{0,25}(pain|bleed|cramp)'
+      - '(pregnant|positive\s+test).{0,30}(dizzy|faint|lightheaded|pale|cold|clammy)'
+  medium:
+    phrases:
+      - 'pregnant with cramping'
+      - 'one-sided pelvic pain and pregnant'
+      - 'pregnant and lower belly pain'
+      - 'abdominal pain in early pregnancy'
+      - 'pain and might be pregnant'
+      - 'pregnant with spotting and pain'
+      - 'light bleeding when I wipe'
+      - 'sharp cramps that come and go'
+      - 'feeling woozy and cramping'
+      - 'cramps are sharp'
+      - 'pain spikes and then calms down'
+      - 'got really pale'
+      - 'felt floaty'
+      - 'bleeding like spotting'
+      - 'pink to brown spotting'
+      - 'my period is late and I have pain on one side'
+      - 'brownish discharge and pain low down'
+      - 'pain worse on one side than the other'
+      - 'feels like something is pulling inside my pelvis'
+      - 'cramping only on my right side'
+      - 'cramping only on my left side'
+      - 'sharp pinch feeling down low'
+      - 'bleeding is dark red almost brown'
+      - 'I feel faint and my stomach is killing me'
+      - 'something feels wrong with this pregnancy'
+      - 'pain goes into my bum when I sit'
+      - 'rectal pressure and pelvic pain'
+      - 'watery bleeding with clots'
+      - 'had a miscarriage before and having one-sided pain'
+      - 'IUD removed and now pain with spotting'
+      - 'pain that takes my breath away low in my belly'
+      - 'dizzy when I stand and I have been spotting'
+      - 'my right side feels like it is being stabbed'
+      - 'my left side feels like it is being stabbed'
+      # --- MINIMIZER coverage ---
+      - "there might have been some spotting"
+      - "not exactly sharp, more like a crampy pressure"
+      - "it kind of moves around, maybe just indigestion"
+      - "a little bit of spotting I guess"
+      - "tenderness but not sure if that counts as pain"
+      - "probably just normal pregnancy stuff"
+      - "cramps aren't that bad, just kind of there"
+      - "just some light bleeding, probably nothing"
+      - "a bit of discomfort on one side"
+      - "spotting is probably just normal"
+    regex:
+      - '(cramp|pain).*(one[- ]?sided|right\s+side|left\s+side)'
+      - '(light|mild)\s+(bleed|spot).*wipe'
+      - '(woozy|dizzy|lightheaded).*(cramp|pain|bleed)'
+      - 'spotting.*(not\s+)?(heavy|soaking|filling)'
+      - '(sharp|stabbing).*(cramp|pain|pinch).*(come|wave)'
+      - 'soaking\s+through\s+pads'
+      - 'sharp-?ish\s+(cramp|pain)'
+      - '(sweaty|shaky|pale).*(stomach|belly|abdomen|cramp)'
+      - '(stomach|belly).*(weird|off|funny|uncomfortable)'
+      - 'felt.*(floaty|faint|woozy|dizzy)'
+      - '(period|menstrual).{0,15}(late|missed|overdue).{0,25}pain'
+      - '(brown|dark\s+red|watery).{0,15}(discharge|bleed|blood|spotting)'
+      - '(pull|tug|twist).{0,15}(inside|pelv|lower|low\s+down)'
+      - '(rectal|bum|bottom)\s+(pressure|pain).{0,20}(pelv|cramp|bleed)'
+      - '(miscarriage|ectopic)\s+(before|history|previous).{0,20}(pain|bleed|spot)'
+      - '(breath\s+away|double\s+over|doubled\s+over).{0,20}(belly|pelv|lower|pain)'
+      - '(IUD|coil).{0,15}(remov|taken\s+out).{0,20}(pain|bleed|spot)'
+      - '(faint|dizzy|lightheaded).{0,20}(stand|stood|get\s+up).{0,20}(spot|bleed)'
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(just|only).{0,10}(a\\s+)?(little|bit|slight|some).{0,10}(spotting|bleeding|cramp|discomfort|tender).{0,20}(pregnant|pregnancy|positive test|missed period)"
+      - "(pregnant|pregnancy|positive test).{0,25}(just|only).{0,10}(a\\s+)?(little|bit|slight|some).{0,10}(spotting|bleeding|cramp|discomfort|tender)"
+      - "(probably|might be).{0,10}(just|nothing|normal|fine).{0,20}(spotting|bleeding|cramp|pregnancy)"
+      - "(cramp|pain|discomfort|tender).{0,15}(kind of|sort of|not really|not exactly|not sure).{0,15}(sharp|bad|serious|count)"
+      - "(spotting|bleeding).{0,15}(probably|might be|could be).{0,10}(just|nothing|normal|fine|implantation)"
+      # --- additional early pregnancy risk ---
+      - "(pregnant|positive\\s+test).{0,25}(sharp|stab|severe|sudden)\\s+(pain|cramp)"
+      - "(bleeding|spotting).{0,20}(heavier|getting worse|increasing|more)"
+  low:
+    partials:
+      - 'ectopic'
+      - 'pregnant pain'
+      - 'pelvic pain pregnant'
+      - 'spotting'
+      - 'cramping'
+      - 'one-sided pain'
+      - 'bleeding when I wipe'
+      - 'woozy'
+      - 'pinch feeling'
+      - 'shoulder tip pain'
+      - 'late period pain'
+      - 'brown discharge'
+      - 'early pregnancy pain'
+      - 'pelvic pressure'
+      - 'tubal pregnancy'
+      - 'pain low down'
+      - 'implantation pain'
+      - 'positive test pain'
+
+negation_handling:
+  patterns:
+    - 'no abdominal pain during pregnancy'
+    - 'not pregnant'
+    - 'cramping resolved'
+    - 'not soaking pads'
+    - 'bleeding stopped'
+    - 'pain has gone away'
+    - 'no longer spotting'
+    - 'spotting stopped on its own'
+    - 'ectopic was ruled out'
+    - 'scan showed normal pregnancy'
+    - 'confirmed intrauterine pregnancy'
+    - 'no pelvic pain'
+    - 'not having any bleeding'
+    - 'pregnancy test was negative'
+    - 'pain completely resolved'
+    - 'ultrasound was normal'
+    - 'definitely not pregnant'
+    - 'tubes were tied'
+    - 'had a hysterectomy'
+    - 'bleeding was just my period'
+    - 'cramps went away after paracetamol'
+  action: downgrade_confidence
diff --git a/list/taxonomy/exertional_dyspnea/flows/clarify.yaml b/list/taxonomy/exertional_dyspnea/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..cb1b73233fe4ebcdd6b5a6edc319cd9cde1ebc6d
--- /dev/null
+++ b/list/taxonomy/exertional_dyspnea/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: exertional_dyspnea
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: exertional_dyspnea_clarify
+      goal: "Ask patient to describe their exertional dyspnea symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - exertional_dyspnea_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/exertional_dyspnea/flows/escalate_r1.yaml b/list/taxonomy/exertional_dyspnea/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a69676e661caa46e89a8f875efce8fa15d4e44a7
--- /dev/null
+++ b/list/taxonomy/exertional_dyspnea/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: exertional_dyspnea
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/exertional_dyspnea/flows/escalate_r3.yaml b/list/taxonomy/exertional_dyspnea/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..fe8fe8138298b83112249e0f0e9eda9bdf6d06a1
--- /dev/null
+++ b/list/taxonomy/exertional_dyspnea/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: exertional_dyspnea
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Instruct patient to call 911 immediately and inform them of nurse transfer
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/exertional_dyspnea/flows/handoff.yaml b/list/taxonomy/exertional_dyspnea/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1c5b39bb153895858502ff910dc6c5857f1c24bb
--- /dev/null
+++ b/list/taxonomy/exertional_dyspnea/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: exertional_dyspnea
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: exertional_dyspnea_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: exertional_dyspnea_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/exertional_dyspnea/flows/safety_screen.yaml b/list/taxonomy/exertional_dyspnea/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6ef0db43482604a2b69f65c1e798851b3131c7a5
--- /dev/null
+++ b/list/taxonomy/exertional_dyspnea/flows/safety_screen.yaml
@@ -0,0 +1,33 @@
+flow_id: safety_screen
+type: screening
+domain: exertional_dyspnea
+
+required_slots:
+  - dyspnea_onset
+  - dyspnea_duration
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: exertional_dyspnea_screen_step1
+      goal: "Determine whether dyspnea is new onset or chronic worsening"
+      tone: calm_urgent
+      must_include:
+        - "shortness of breath"
+      must_ask:
+        - "When did you first notice the shortness of breath with activity?"
+        - "Is this something new, or has it been going on for a while?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - dyspnea_onset
+      - dyspnea_duration
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_low_risk: escalate_r1
+  on_unclear: escalate_r3
diff --git a/list/taxonomy/exertional_dyspnea/rules.yaml b/list/taxonomy/exertional_dyspnea/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e4771c0b120f7d9b155dbeaa789bbc862f13bb6f
--- /dev/null
+++ b/list/taxonomy/exertional_dyspnea/rules.yaml
@@ -0,0 +1,33 @@
+domain: exertional_dyspnea
+target_risk_class: R3
+
+decision_rules:
+  - id: exertional_dyspnea_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: exertional_dyspnea_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: exertional_dyspnea_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: exertional_dyspnea_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: exertional_dyspnea_r1_escalation
+    if:
+      risk_class: R1
+    then:
+      flow: escalate_r1
diff --git a/list/taxonomy/exertional_dyspnea/triggers.yaml b/list/taxonomy/exertional_dyspnea/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..71fd7a0f8383d59e61aa895a0d3e7584b5392a5d
--- /dev/null
+++ b/list/taxonomy/exertional_dyspnea/triggers.yaml
@@ -0,0 +1,117 @@
+domain: exertional_dyspnea
+priority: 39
+
+lexical_signals:
+  high:
+    phrases:
+      - "short of breath when I walk"
+      - "can't breathe on exertion"
+      - "winded going up stairs"
+      - "breathless with any activity"
+      - "shortness of breath with exercise"
+      - "out of breath just walking to bathroom"
+      - "can't walk without getting winded"
+      - "short of breath doing simple things"
+      - "huffing and puffing going up stairs"
+      - "out of breath walking across the room"
+      - "can barely walk without stopping to breathe"
+      - "get winded doing anything physical"
+      - "short of breath when I move around"
+    regex:
+      - "short(ness)?\\s+of\\s+breath.*(walk|exert|stair|activ|mov|simple|doing)"
+      - "(winded|breathless).*(walk|exert|stair|activ|mov|doing)"
+      - "(out\\s+of|short\\s+of)\\s+breath.*(walk|stair|room|bath|mov)"
+      - "(can'?t|can\\s+barely)\\s+(walk|move|breathe).*(without|exert|stair)"
+      - "(huffing|puffing|gasping).*(stair|walk|exert)"
+  medium:
+    phrases:
+      - "more short of breath with activity"
+      - "getting winded more easily"
+      - "breathless when walking"
+      - "exertion makes me breathless"
+      - "out of breath with movement"
+      - "need to rest after walking"
+      - "having trouble catching my breath"
+      - "winded easily"
+      - "breathing harder with activity"
+      - "get tired quickly when moving"
+      - "can't do as much as before"
+      # --- additional naturalistic ---
+      - "I have to stop and catch my breath"
+      - "can't even walk to the mailbox"
+      - "used to be able to do this without getting winded"
+  low:
+    partials:
+      - "exertional dyspnea"
+      - "winded"
+      - "breathless activity"
+      - "out of breath"
+      - "short of breath walking"
+
+negation_handling:
+  patterns:
+    - "no shortness of breath with activity"
+    - "breathing fine with exercise"
+    - "not winded"
+    - "no shortness of breath"
+    - "not short of breath"
+    - "breathing fine"
+    - "breathing is fine"
+    - "breathing normally"
+    - "can breathe okay"
+    - "no trouble breathing"
+    - "no difficulty breathing"
+    # --- baseline / recovery context ---
+    - "that's normal for me"
+    - "always been like that"
+    - "always get winded"
+    - "been that way since"
+    - "getting better"
+    - "getting better though"
+    - "improving"
+    - "used to be worse"
+    - "better than before"
+    - "better than it was"
+    - "normal for my age"
+    - "doctor said that's expected"
+    - "I just need to take it easy"
+    - "I just need to pace myself"
+    - "I know I need to take it slow"
+    - "but I'm okay once I sit down"
+    - "but it goes away when I rest"
+    - "gotta pause"
+    - "have to pause"
+    - "if I go too fast"
+    - "only if I rush"
+    - "only when I push too hard"
+    # --- historical / administrative context (FDA-safe) ---
+    - "years ago"
+    - "in the past"
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "routine check"
+    - "just a question"
+  # Changed from 'suppress' to 'downgrade_confidence' for FDA Non-Device CDS compliance.
+  # Baseline patterns reduce confidence rather than ruling out exertional origin.
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_has_condition: ["I50.*"]
+        patient_on_medication: ["furosemide", "bumetanide", "torsemide"]
+      reason: "CHF patient on diuretic -- dyspnea is decompensation signal"
+    - when:
+        patient_has_condition: ["J44.*"]
+        recent_lab:
+          code: "2160-0"
+          value_above: 1.5
+          within_days: 60
+      reason: "COPD patient with elevated creatinine -- cardiopulmonary concern"
+  boost_to_medium:
+    - when:
+        patient_has_condition: ["I50.*"]
+      reason: "CHF history raises concern for exertional dyspnea"
+    - when:
+        patient_has_condition: ["J44.*"]
+      reason: "COPD history raises concern for exertional dyspnea"
diff --git a/list/taxonomy/fall_high_risk/flows/clarify.yaml b/list/taxonomy/fall_high_risk/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e8ba41b6e1e1bcc6ee6204c116114f60a897ada0
--- /dev/null
+++ b/list/taxonomy/fall_high_risk/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: fall_high_risk
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: fall_high_risk_clarify
+      goal: "Ask patient to describe their fall high risk symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - fall_high_risk_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/fall_high_risk/flows/escalate_r2.yaml b/list/taxonomy/fall_high_risk/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0190cbdbbcbadc9e948572770ec162516423838a
--- /dev/null
+++ b/list/taxonomy/fall_high_risk/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: fall_high_risk
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/fall_high_risk/flows/escalate_r3.yaml b/list/taxonomy/fall_high_risk/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7edf9cf75201726639615f35b720c346f5f6fd3a
--- /dev/null
+++ b/list/taxonomy/fall_high_risk/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: fall_high_risk
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Instruct patient to call 911 immediately and inform them of nurse transfer
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/fall_high_risk/flows/handoff.yaml b/list/taxonomy/fall_high_risk/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..25736914e3555d5f2a1bff05683d6b7b37508bd3
--- /dev/null
+++ b/list/taxonomy/fall_high_risk/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: fall_high_risk
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: fall_high_risk_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: fall_high_risk_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/fall_high_risk/flows/reassure_low_risk.yaml b/list/taxonomy/fall_high_risk/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..521987ab30ad9af225f336a3ec13c35e730d0c12
--- /dev/null
+++ b/list/taxonomy/fall_high_risk/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: fall_high_risk
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: fall_high_risk_reassure
+      goal: "Acknowledge the patient's concern about their fall, note that their care team will be informed for routine follow-up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/fall_high_risk/flows/safety_screen.yaml b/list/taxonomy/fall_high_risk/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9733118f6c2f2c9db509b3eb1f6dec2d1e086378
--- /dev/null
+++ b/list/taxonomy/fall_high_risk/flows/safety_screen.yaml
@@ -0,0 +1,55 @@
+flow_id: safety_screen
+type: screening
+domain: fall_high_risk
+
+required_slots:
+  - head_strike
+  - on_anticoagulant
+  - injury_present
+  - loss_of_consciousness
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: fall_high_risk_screen_step1
+      goal: "Determine whether the fall involved head impact or injury"
+      tone: calm_urgent
+      must_include:
+        - "fall"
+      must_ask:
+        - "Did you hit your head during the fall?"
+        - "Do you have any injuries — cuts, bruises, or pain anywhere?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - head_strike
+      - injury_present
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: fall_high_risk_screen_step2
+      goal: "Screen for high-risk fall factors"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "Are you on any blood thinners or anticoagulant medications?"
+        - "Did you lose consciousness or black out at any point?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - on_anticoagulant
+      - loss_of_consciousness
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_r2: escalate_r2
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_r3
diff --git a/list/taxonomy/fall_high_risk/rules.yaml b/list/taxonomy/fall_high_risk/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d8ec15d4ca8a4fa690f02dbc2795938ea52cc51e
--- /dev/null
+++ b/list/taxonomy/fall_high_risk/rules.yaml
@@ -0,0 +1,33 @@
+domain: fall_high_risk
+target_risk_class: R2
+
+decision_rules:
+  - id: fall_high_risk_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: fall_high_risk_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: fall_high_risk_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: fall_high_risk_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: fall_high_risk_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/fall_high_risk/triggers.yaml b/list/taxonomy/fall_high_risk/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..83c28a9955a6d6d9afeeca9558139bd91ef4d63a
--- /dev/null
+++ b/list/taxonomy/fall_high_risk/triggers.yaml
@@ -0,0 +1,192 @@
+domain: fall_high_risk
+priority: 76
+
+lexical_signals:
+  high:
+    phrases:
+      - 'fell and hit my head'
+      - 'fall on blood thinners'
+      - 'fell and I''m on anticoagulants'
+      - 'head strike from fall'
+      - 'fell and take warfarin'
+      - 'fell and hit my head while on anticoagulation'
+      - 'took a bad fall and hit my head'
+      - 'fell down the stairs'
+      - 'fell and can''t get up'
+      - 'fell and I take blood thinning tablets'
+      - 'dad fell and he is on warfarin'
+      - 'mum has fallen and bumped her head and she takes eliquis'
+      - 'had a fall and I''m confused and on blood thinners'
+      - 'fell and lost consciousness'
+      - 'fell and now can''t move my arm'
+      - 'fell off a ladder and hit my head'
+      - 'multiple falls this week'
+      - 'keeps falling over and over'
+      - 'fell and there is a big lump on the head'
+      - 'knocked out after a fall'
+      - 'fell and on apixaban'
+      - 'hit head on the floor when I collapsed'
+    regex:
+      - 'fell\s+and\s+(hit|struck)\s+(my\s+)?head'
+      - 'fall.*blood\s+thinner'
+      - '(fell|fall).{0,20}(warfarin|coumadin|eliquis|xarelto|apixaban|rivaroxaban|edoxaban|dabigatran|blood\s+thinner|anticoagul|thinn)'
+      - 'fell\s+(down\s+)?(the\s+)?stairs'
+      - '(fell|fall).{0,15}(can''?t|couldn''?t)\s+(get\s+)?up'
+      - '(fell|fall).{0,15}(lost|lose)\s+(conscious|awareness)'
+      - '(fell|fall).{0,15}(can''?t|couldn''?t)\s+(move|feel)\s+(my\s+)?(arm|leg|hand|foot|hip|wrist)'
+      - '(fell|fall|drop).{0,10}(off|from)\s+(a\s+)?(ladder|roof|height|chair|bed|stool)'
+      - '(multiple|several|keeps?|repeat).{0,10}(fall|fell|falling)'
+      - '(knocked?\s+out|unconscious|blacked?\s+out).{0,15}(fall|fell|hit)'
+      - '(head|skull|temple|forehead).{0,10}(hit|struck|crack|bang|bump).{0,15}(floor|ground|wall|table|concrete)'
+      - '(collapsed|fainted|passed\s+out).{0,15}(hit|struck|bump).{0,10}(head|skull|floor)'
+  medium:
+    phrases:
+      - 'fell and on blood thinners'
+      - 'took a fall and bumped my head'
+      - 'fell down and hit my head'
+      - 'lost balance and fell'
+      - 'fall with head injury'
+      - 'fell today on anticoagulants'
+      - 'fell in the bathroom'
+      - 'fell getting out of bed'
+      - 'fell off the chair'
+      - 'tripped and fell hard'
+      - 'slipped and fell'
+      - 'took a tumble'
+      - 'legs gave out'
+      - 'knees buckled and I went down'
+      - 'fell and something popped'
+      - 'went down hard'
+      - 'lost my balance'
+      - 'ground just came up'
+      - 'fell and my hip is really sore'
+      - 'fell and my wrist is swollen'
+      - 'nan had a fall in the care home'
+      - 'grandad has fallen again'
+      - 'found her on the floor'
+      - 'lying on the floor when I got home'
+      - 'fell and now feels sick and dizzy'
+      - 'hit the back of my head on the ground'
+      - 'landed on my face'
+      - 'slipped on ice and went flying'
+      - 'tripped on the rug and landed hard'
+      - 'blacked out and woke up on the floor'
+      - 'fell and there is a lot of bruising'
+      - 'fell and cut my head open'
+      - 'fell and my head is bleeding'
+      - 'can''t weight bear after the fall'
+      - 'hip gave way and I went down'
+      - 'feel unsteady and keep nearly falling'
+      - 'fell and feeling drowsy afterwards'
+      # --- MINIMIZER coverage ---
+      - "it wasn't a bad fall, just a little stumble"
+      - "I just tripped a bit, nothing serious"
+      - "barely fell, caught myself mostly"
+      - "just a minor spill"
+      - "I stumbled but I'm fine"
+      - "head might be a little sore"
+      - "just lost my balance for a second"
+      - "I just slipped a little"
+      - "bumped my head but I'm okay"
+      - "took a little tumble, nothing major"
+      - "I kind of went down but it wasn't that bad"
+      - "knee is a bit sore from a little fall"
+      - "wasn't really a fall, more of a stumble"
+      # --- additional caregiver report ---
+      - "he fell and won't get up"
+      - "she fell and is confused"
+      - "found him on the ground"
+    regex:
+      - '(fell|fall|tripped|slipped).{0,20}(hard|bad|badly|down|floor|ground|bathroom|kitchen|stairs)'
+      - '(legs?|knees?|balance).{0,15}(gave|buckl|lost|went)'
+      - '(took|had)\s+a\s+(bad\s+)?(fall|tumble|spill)'
+      - '(bump|hit|strike|crack|bang|smack).{0,15}(head|skull|forehead|temple)'
+      - '(fell|fall|down).{0,20}(bruise|swell|hurt|pain|sore|bleed|cut|gash)'
+      - '(lightheaded|dizzy|woozy|faint).{0,20}(fell|fall|went\s+down)'
+      - '(found|lying|lay).{0,10}(on\s+the\s+)?(floor|ground|pavement|carpet)'
+      - '(nan|nana|grandad|grandfather|grandmother|granny|gran|elderly).{0,20}(fell|fall|fallen|tumble)'
+      - '(fell|fall).{0,15}(hip|wrist|arm|shoulder|knee|ankle).{0,10}(sore|hurt|pain|swell|swollen)'
+      - '(black|pass).{0,5}(out|ed\s+out).{0,15}(floor|ground|woke\s+up)'
+      - '(fell|fall).{0,15}(cut|gash|lacerat|bleed).{0,10}(head|forehead|scalp|face)'
+      - '(can''?t|unable).{0,10}(weight\s+bear|stand|put\s+weight).{0,15}(fall|fell)'
+      - '(unsteady|wobbly|shaky).{0,15}(feet|legs?|walk|stand).{0,15}(fall|nearly)'
+      - '(drowsy|confused|sleepy|vomit).{0,15}(after|since|following).{0,10}(fall|fell|hit|bang)'
+      - '(slipped|tripped).{0,20}(ice|wet|rug|carpet|mat|curb|step|puddle|water|tile|floor)'
+      - '(head|skull|temple).{0,15}(bump|hit|struck|bang|smack).{0,15}(table|cabinet|furniture|counter|edge|shelf|wall)'
+      - '(apixaban|warfarin|eliquis|xarelto|blood\s+thinner|anticoagul).{0,100}(fell|fall|slip|trip|down|floor)'
+      - '(fell|fall|slip|trip|down|floor).{0,100}(apixaban|warfarin|eliquis|xarelto|blood\s+thinner|anticoagul)'
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(just|only).{0,10}(a\\s+)?(little|bit|minor|small|slight).{0,10}(fall|tumble|spill|stumble|trip|slip)"
+      - "(wasn'?t|not).{0,10}(a\\s+)?(bad|serious|real|big).{0,10}(fall|tumble|trip)"
+      - "(fell|tripped|slipped|stumbled).{0,15}(but|though).{0,15}(fine|okay|nothing|not that bad|not serious)"
+      - "(barely|almost|kind of|sort of).{0,10}(fell|tripped|went down|stumbled|slipped)"
+      - "(head|knee|hip|wrist|elbow).{0,15}(a\\s+)?(bit|little|kind of|sort of).{0,15}(sore|bruised|tender|achy).{0,15}(fall|fell|trip|stumble)"
+  low:
+    partials:
+      - 'fell'
+      - 'fall'
+      - 'head strike'
+      - 'anticoagulant fall'
+      - 'tripped'
+      - 'slipped'
+      - 'lost balance'
+      - 'went down'
+      - 'took a fall'
+      - 'tumble'
+      - 'found on floor'
+      - 'unsteady'
+      - 'wobbly on feet'
+      - 'collapse'
+      - 'blacked out'
+      - 'head bump'
+      - 'bruising after fall'
+      - 'mechanical fall'
+
+negation_handling:
+  patterns:
+    - 'didn''t fall'
+    - 'no falls'
+    - 'haven''t fallen'
+    - 'caught myself'
+    - 'almost fell but didn''t'
+    - 'no head injury'
+    - 'didn''t hit my head'
+    - 'no loss of consciousness'
+    - 'fall was weeks ago and fully recovered'
+    - 'not on any blood thinners'
+    - 'steady on feet'
+    - 'walking fine now'
+    - 'just stumbled but did not go down'
+    - 'grabbed the rail and caught myself'
+    - 'no bruising or swelling after the fall'
+    - 'head is fine after the bump'
+    - 'fall happened months ago'
+    - 'been checked after the fall and cleared'
+    - 'CT scan was normal after the fall'
+    - 'near miss but no actual fall'
+    - 'tripped but stayed on my feet'
+    # --- non-fall contexts (R1 scenarios) ---
+    - "falling behind"
+    - "fall behind"
+    - "fell behind"
+    - "fall prevention"
+    - "fall asleep"
+    - "fell asleep"
+    - "fall risk assessment"
+    - "fall into place"
+    - "fell into place"
+    - "downfall"
+    - "rainfall"
+    - "waterfall"
+    - "fall appointment"
+    - "fall cleanup"
+    - "fall season"
+    - "the fall"
+    - "last fall"
+    - "this fall"
+    - "in the fall"
+    - "fall through"
+    - "fall off the wagon"
+    - "let it fall"
+    - "fall back"
+  action: downgrade_confidence
diff --git a/list/taxonomy/febrile_neutropenia/flows/clarify.yaml b/list/taxonomy/febrile_neutropenia/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1e6d3ba1073b117564e5f61d06f3d16f2d6676a3
--- /dev/null
+++ b/list/taxonomy/febrile_neutropenia/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: febrile_neutropenia
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: febrile_neutropenia_clarify
+      goal: "Ask patient to describe their febrile neutropenia symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - febrile_neutropenia_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/febrile_neutropenia/flows/escalate_r3.yaml b/list/taxonomy/febrile_neutropenia/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4d2eb719143638c5bb525347cd14f1c59723c394
--- /dev/null
+++ b/list/taxonomy/febrile_neutropenia/flows/escalate_r3.yaml
@@ -0,0 +1,38 @@
+flow_id: escalate_r3
+type: escalation
+domain: febrile_neutropenia
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Inform patient this requires immediate clinical attention and they will
+      be transferred
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/febrile_neutropenia/flows/handoff.yaml b/list/taxonomy/febrile_neutropenia/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9b337937749d04f16b1229154e1250fa3c6fea87
--- /dev/null
+++ b/list/taxonomy/febrile_neutropenia/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: febrile_neutropenia
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: febrile_neutropenia_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: febrile_neutropenia_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/febrile_neutropenia/rules.yaml b/list/taxonomy/febrile_neutropenia/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4f4d7d94ba2a3e6203930b14722a569bd1caf106
--- /dev/null
+++ b/list/taxonomy/febrile_neutropenia/rules.yaml
@@ -0,0 +1,21 @@
+domain: febrile_neutropenia
+target_risk_class: R3
+
+decision_rules:
+  - id: febrile_neutropenia_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r3
+
+  - id: febrile_neutropenia_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r3
+
+  - id: febrile_neutropenia_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/febrile_neutropenia/triggers.yaml b/list/taxonomy/febrile_neutropenia/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7c33e40c5cfe5d8e40f013ced0f96a52c6b76985
--- /dev/null
+++ b/list/taxonomy/febrile_neutropenia/triggers.yaml
@@ -0,0 +1,65 @@
+domain: febrile_neutropenia
+priority: 85
+
+lexical_signals:
+  high:
+    phrases:
+      - "fever and just had chemo"
+      - "neutropenic fever"
+      - "febrile neutropenia"
+      - "fever with low white count"
+      - "temperature 101 and on chemotherapy"
+      - "high fever after cancer treatment"
+      - "fever and on chemo"
+      - "chills and on chemo"
+    regex:
+      - "(febrile|fever)\\s+(and\\s+)?neutrop"
+      - "fever\\s+(after|and|during)\\s+chemo"
+      - "(fever|temperature|temp).{0,40}(chemo|chemotherapy|cancer treatment|oncolog)"
+      - "(chemo|chemotherapy|cancer treatment).{0,40}(fever|temperature|temp|101|102|103|38)"
+      - "(chills|shaking|shiver).{0,40}(chemo|chemotherapy|cancer treatment)"
+      # --- chemo + fever combination ---
+      - "(fever|temp|temperature).{0,30}(since|after|following).{0,20}(treatment|infusion|session)"
+      - "(got|have|running|developed).{0,15}(a )?fever.{0,30}(chemo|chemotherapy|treatment)"
+      - "(last|recent).{0,15}(chemo|chemotherapy|treatment).{0,30}(fever|temp|temperature)"
+      # --- immunocompromised context ---
+      - "(on|receiving|getting|having).{0,15}(chemo|chemotherapy).{0,30}(and|with).{0,15}(fever|temp|temperature)"
+      - "(low|no|depleted).{0,15}(white|wbc|immune|blood).{0,20}(count|cells?|system).{0,30}(fever|temp)"
+      - "(fever|temp).{0,30}(low|no|depleted).{0,15}(white|wbc|immune|blood).{0,20}(count|cells?|system)"
+      - "(immunocompromised|immunosuppressed|weak immune).{0,30}(fever|temp|temperature|101|102)"
+      # --- urgency language ---
+      - "(oncologist|doctor|nurse|they).{0,20}(said|told|warned).{0,30}(call|come in|emergency).{0,20}(if|when).{0,15}fever"
+      - "(told|said|warned).{0,20}fever.{0,20}(emergency|serious|dangerous|urgent|come in|call)"
+      - "fever.{0,20}(emergency|serious|dangerous).{0,20}(with|on|during).{0,20}(chemo|chemotherapy|treatment)"
+      - "(any|even a little|slight).{0,10}fever.{0,30}(chemo|chemotherapy|treatment)"
+  medium:
+    phrases:
+      - "fever after chemo"
+      - "chills and on chemotherapy"
+      - "temperature up and immunosuppressed"
+      - "fever and immunocompromised"
+      - "fever on cancer treatment"
+      - "took my temperature twice"
+      - "running a fever and on chemo"
+      - "101 degrees and on chemotherapy"
+      - "102 degrees after chemo"
+    regex:
+      - "(immunosuppress|immunocompromis).{0,30}(fever|temp|101|102)"
+      - "(fever|temp).{0,30}(immunosuppress|immunocompromis)"
+      - "on\\s+(chemo|chemotherapy).{0,40}(fever|temperature|chills)"
+      - "(101|102|103|38\\.[0-9]).*chemo"
+      - "chemo.*(101|102|103|38\\.[0-9])"
+  low:
+    partials:
+      - "neutropenic"
+      - "chemo fever"
+      - "immunosuppressed fever"
+      - "on chemotherapy"
+      - "cancer treatment"
+
+negation_handling:
+  patterns:
+    - "no fever"
+    - "temperature normal"
+    - "feeling fine after chemo"
+  action: downgrade_confidence
diff --git a/list/taxonomy/food_insecurity/flows/clarify.yaml b/list/taxonomy/food_insecurity/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d0ad2d137a1f1bacd33a165ad0440b04eb4b1b20
--- /dev/null
+++ b/list/taxonomy/food_insecurity/flows/clarify.yaml
@@ -0,0 +1,26 @@
+flow_id: clarify
+type: clarification
+domain: food_insecurity
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: food_insecurity_clarify
+      goal: "Ask the patient to tell more about their food access situation"
+      tone: warm_empathetic
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "charity"
+        - "welfare"
+        - "poor"
+      max_questions: 1
+    collects:
+      - food_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/food_insecurity/flows/community_resource_referral.yaml b/list/taxonomy/food_insecurity/flows/community_resource_referral.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..506a3e13638b8794bd0176f14b6521679bee8800
--- /dev/null
+++ b/list/taxonomy/food_insecurity/flows/community_resource_referral.yaml
@@ -0,0 +1,24 @@
+flow_id: community_resource_referral
+type: resolution
+domain: food_insecurity
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: food_community_resource_referral
+      goal: "Inform the patient that their care team will connect them with food assistance resources in their community"
+      tone: warm_empathetic
+      must_include:
+        - "care team"
+        - "resources"
+        - "food"
+      must_not:
+        - "charity"
+        - "welfare"
+        - "poor"
+        - "handout"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/food_insecurity/flows/food_screen.yaml b/list/taxonomy/food_insecurity/flows/food_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5bb05828a493b84d47dca129b7e471d6b142a64a
--- /dev/null
+++ b/list/taxonomy/food_insecurity/flows/food_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: food_screen
+type: screening
+domain: food_insecurity
+
+required_slots:
+  - food_access
+  - household_size
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: food_screen_step1
+      goal: "Assess the severity of food access issues and household composition"
+      tone: warm_empathetic
+      must_include:
+        - "food"
+      must_ask:
+        - "Can you tell me more about what's going on with your food situation?"
+        - "How many people are in your household?"
+      must_not:
+        - "charity"
+        - "welfare"
+        - "poor"
+        - "can't afford"
+      max_questions: 2
+    collects:
+      - food_access
+      - household_size
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: food_screen_step2
+      goal: "Ask about current assistance programs enrollment"
+      tone: warm_empathetic
+      must_include:
+        - "help"
+      must_ask:
+        - "Are you currently enrolled in any food assistance programs?"
+      must_not:
+        - "welfare"
+        - "handout"
+        - "charity"
+      max_questions: 1
+    collects:
+      - snap_enrolled
+
+exit:
+  on_complete: evaluate_concern
+  on_concern: community_resource_referral
+  on_low_risk: community_resource_referral
+  on_unclear: community_resource_referral
diff --git a/list/taxonomy/food_insecurity/rules.yaml b/list/taxonomy/food_insecurity/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..cb5ab02d052c2908e220e206b3abd5f8d815bd89
--- /dev/null
+++ b/list/taxonomy/food_insecurity/rules.yaml
@@ -0,0 +1,27 @@
+domain: food_insecurity
+target_risk_class: R1
+
+decision_rules:
+  - id: food_insecurity_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: food_screen
+
+  - id: food_insecurity_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: food_screen
+
+  - id: food_insecurity_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: food_insecurity_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: community_resource_referral
diff --git a/list/taxonomy/food_insecurity/triggers.yaml b/list/taxonomy/food_insecurity/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..98ac0803684e0aae89aa3c6e8653d17ad92746ef
--- /dev/null
+++ b/list/taxonomy/food_insecurity/triggers.yaml
@@ -0,0 +1,75 @@
+domain: food_insecurity
+priority: 33
+
+lexical_signals:
+  high:
+    phrases:
+      - "can't afford food"
+      - "skipping meals because I can't afford them"
+      - "running out of food"
+      - "not enough to eat"
+      - "kids are going hungry"
+      - "go to bed hungry"
+      - "haven't eaten in days"
+      - "no money for groceries"
+      - "choosing between food and medicine"
+      - "can't feed my family"
+      - "food bank ran out"
+      - "rationing food"
+      - "cutting back meals to afford rent"
+      - "no food in the house"
+    regex:
+      - "(can't|cannot|unable\\s+to)\\s+(afford|buy|get).{0,15}(food|groceries|meals|enough\\s+to\\s+eat)"
+      - "(skipping|skip|miss|missing)\\s+meals?.{0,15}(can't\\s+afford|no\\s+money|cost)"
+      - "(running|ran)\\s+out\\s+of.{0,10}(food|groceries)"
+      - "(not\\s+enough|no\\s+money\\s+for|can't\\s+pay\\s+for).{0,10}(food|groceries|meals|to\\s+eat)"
+      - "(go|going)\\s+to\\s+bed.{0,10}(hungry|without\\s+eating)"
+      - "(choosing|choose)\\s+between.{0,15}(food|medicine|medication|rent|bills)"
+  medium:
+    phrases:
+      - "skipping meals"
+      - "food bank"
+      - "hungry a lot"
+      - "food stamps"
+      - "need help with food"
+      - "can't get enough food"
+      - "groceries are too expensive"
+      - "struggling to eat"
+      - "worried about food"
+      - "food pantry"
+      - "SNAP benefits"
+      - "running low on food"
+      - "WIC"
+      - "meals on wheels"
+    regex:
+      - "(skip|skipping|missing)\\s+(meals?|breakfast|lunch|dinner)"
+      - "(food|grocery).{0,10}(bank|pantry|stamps|assistance|help)"
+      - "(hungry|hunger).{0,10}(a\\s+lot|often|frequently|all\\s+the\\s+time)"
+      - "(struggling|trouble|hard\\s+time).{0,10}(eat|afford|get).{0,10}(food|meals|groceries)"
+  low:
+    partials:
+      - "hungry"
+      - "food"
+      - "groceries"
+      - "meals"
+      - "food stamps"
+
+negation_handling:
+  patterns:
+    - "have enough food"
+    - "eating well"
+    - "no food issues"
+    - "groceries are fine"
+    - "eating three meals a day"
+    - "plenty of food"
+    - "food is not a problem"
+    - "well fed"
+    - "stocked up on food"
+    - "no trouble with food"
+    - "eating regularly"
+    - "food situation is fine"
+    - "not hungry"
+    - "getting enough to eat"
+    - "meals are covered"
+    - "no issues with food"
+  action: downgrade_confidence
diff --git a/list/taxonomy/gi_bleed/flows/clarify.yaml b/list/taxonomy/gi_bleed/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..235ed1c0c2703390856b9e20a67b0e2b6f42c6bd
--- /dev/null
+++ b/list/taxonomy/gi_bleed/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: gi_bleed
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: gi_bleed_clarify
+      goal: "Ask patient to describe their gi bleed symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - gi_bleed_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/gi_bleed/flows/escalate_r2.yaml b/list/taxonomy/gi_bleed/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8446996e163f6cc99a91863e910aa93db8307b12
--- /dev/null
+++ b/list/taxonomy/gi_bleed/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: gi_bleed
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/gi_bleed/flows/escalate_r3.yaml b/list/taxonomy/gi_bleed/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b1cf2ea7989198878c2ed58f68f9b14aaf4c9170
--- /dev/null
+++ b/list/taxonomy/gi_bleed/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: gi_bleed
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Instruct patient to call 911 immediately and inform them of nurse transfer
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/gi_bleed/flows/handoff.yaml b/list/taxonomy/gi_bleed/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..877d14ae003e17a3032966cb7935b4401a8aea79
--- /dev/null
+++ b/list/taxonomy/gi_bleed/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: gi_bleed
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: gi_bleed_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: gi_bleed_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/gi_bleed/flows/safety_screen.yaml b/list/taxonomy/gi_bleed/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7abf1deec316678021e888ba9c617a78b7ae743c
--- /dev/null
+++ b/list/taxonomy/gi_bleed/flows/safety_screen.yaml
@@ -0,0 +1,54 @@
+flow_id: safety_screen
+type: screening
+domain: gi_bleed
+
+required_slots:
+  - blood_color
+  - blood_amount
+  - stool_appearance
+  - associated_symptoms
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "blood color"
+        - "blood amount"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - blood_color
+      - blood_amount
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "stool appearance"
+        - "associated symptoms"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - stool_appearance
+      - associated_symptoms
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/list/taxonomy/gi_bleed/rules.yaml b/list/taxonomy/gi_bleed/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ee7f21a606047dd59eeceaf6aa1af349fcacb9ab
--- /dev/null
+++ b/list/taxonomy/gi_bleed/rules.yaml
@@ -0,0 +1,33 @@
+domain: gi_bleed
+target_risk_class: R3
+
+decision_rules:
+  - id: gi_bleed_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: gi_bleed_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: gi_bleed_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: gi_bleed_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: gi_bleed_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/gi_bleed/triggers.yaml b/list/taxonomy/gi_bleed/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..93120212c7a1aaf511bf9fa48baa458c178d80c2
--- /dev/null
+++ b/list/taxonomy/gi_bleed/triggers.yaml
@@ -0,0 +1,193 @@
+domain: gi_bleed
+priority: 80
+
+lexical_signals:
+  high:
+    phrases:
+      # --- original ---
+      - "vomiting blood"
+      - "black tarry stool"
+      - "blood in vomit"
+      - "hematemesis"
+      - "melena"
+      - "bloody stool"
+      - "bright red blood in stool"
+      # --- expanded naturalistic ---
+      - "throwing up blood"
+      - "puking blood"
+      - "coffee ground vomit"
+      - "vomit looks like coffee grounds"
+      - "threw up and it was all blood"
+      - "blood coming up when I vomit"
+      - "bright red blood coming out of my rectum"
+      - "large amount of blood from my bottom"
+      - "passing blood clots from my rectum"
+      - "blood clots in my stool"
+      - "hemorrhaging from my stomach"
+      - "GI hemorrhage"
+      - "massive rectal bleeding"
+      - "stool is pure blood"
+      - "toilet bowl full of blood after bowel movement"
+      - "pooping nothing but blood"
+      - "vomited a large amount of blood"
+      - "maroon colored stool with clots"
+      - "blood pouring from my backside"
+    regex:
+      # --- original ---
+      - "(vomiting|throwing\\s+up)\\s+blood"
+      - "(black|bloody|tarry)\\s+stool"
+      - "(hematemesis|melena)"
+      # --- expanded ---
+      - "(puking|spitting|coughing)\\s+up\\s+blood"
+      - "coffee\\s+ground(s)?\\s+(vomit|emesis|puke)"
+      - "vomit.*(coffee\\s+ground|dark\\s+brown\\s+blood|looks\\s+like\\s+blood)"
+      - "bright\\s+red\\s+blood\\s+(in|from|with)\\s+(stool|rectum|bowel|bottom)"
+      - "(massive|large|heavy|significant)\\s+(amount\\s+of\\s+)?(rectal\\s+)?bleed(ing)?"
+      - "blood\\s+clot(s)?\\s+(in|from|with)\\s+(stool|rectum|bowel)"
+      - "(hemorrhag|GI\\s+bleed|gastrointestinal\\s+bleed)"
+      - "stool\\s+(is\\s+)?(pure|all|nothing\\s+but)\\s+blood"
+      - "toilet\\s+(bowl\\s+)?(full|covered)\\s+(of|with|in)\\s+blood"
+      - "(pooping|passing|having)\\s+(nothing\\s+but|only|pure)\\s+blood"
+      - "threw\\s+up.*(blood|red|coffee)"
+      - "maroon\\s+(colored\\s+)?stool"
+      # --- additional euphemistic ---
+      - "(dark|black)\\s+(stuff|liquid|substance).{0,15}(came up|vomit|threw)"
+  medium:
+    phrases:
+      # --- original ---
+      - "blood when I throw up"
+      - "stool looks very dark"
+      - "noticed blood after vomiting"
+      - "dark stools since discharge"
+      - "rectal bleeding"
+      - "blood streaks in stool"
+      # --- expanded naturalistic ---
+      - "blood in my stool"
+      - "dark stools"
+      - "stools are really dark"
+      - "blood on toilet paper after wiping"
+      - "blood when I wipe"
+      - "passing some blood with bowel movements"
+      - "my bowels are bloody"
+      - "stomach is bleeding"
+      - "some blood mixed in my stool"
+      - "small amount of blood in stool"
+      - "noticed blood in the toilet"
+      - "poop has blood in it"
+      - "dark red blood in stool"
+      - "blood dripping after a bowel movement"
+      - "stools have gotten very dark and sticky"
+      - "my stool is black"
+      - "tar-like stool"
+      - "stool smells metallic and is dark"
+      - "blood spots in my stool"
+      - "I see blood when I go to the bathroom"
+      - "bloody mucus in stool"
+      - "there was blood on the tissue"
+      - "a little blood in my stool"
+      - "traces of blood in bowel movement"
+      - "spotting blood from my rectum"
+      - "my stool has a reddish tinge"
+      - "vomit had some blood in it"
+      - "pink-tinged vomit"
+    regex:
+      - "blood\\s+(on|when)\\s+(the\\s+)?(toilet\\s+paper|tissue|wip)"
+      - "(dark|black|tar|tarry|sticky)\\s+(colored\\s+)?stool(s)?"
+      - "blood\\s+(in|mixed|with|from)\\s+(the\\s+)?(stool|bowel|toilet|poop)"
+      - "(some|small|little|bit\\s+of)\\s+blood\\s+(in|from|with)"
+      - "(passing|spotting|dripping|seeing)\\s+blood\\s+(from|with|during|after)"
+      - "bowel(s)?\\s+(are\\s+)?blood"
+      - "stomach\\s+(is\\s+)?bleed"
+      - "(rectal|anal|bottom)\\s+bleed"
+      - "stool.*(reddish|red|maroon|dark)"
+      - "(bloody|blood)\\s+mucus\\s+(in\\s+)?stool"
+      - "pink\\s*(-)?\\s*tinged\\s+vomit"
+      - "vomit\\s+had\\s+(some\\s+)?blood"
+      - "(bright\\s+red|red).{0,15}(wip|paper|toilet|tissue)"
+      - "clots?.{0,15}(jelly|small|couple|grape|pea)"
+      - "(toilet|water).{0,15}(red|tinted|blood|swirl)"
+      - "(blackish|darkish|almost\\s+black).{0,15}(sticky|stool|poop)"
+      - "(darker\\s+than\\s+normal|darker\\s+than\\s+usual).{0,20}(sticky|black|tar)"
+    partials:
+      - "melena"
+      - "rectal bleeding"
+      - "blood in stool"
+      - "dark stool"
+      - "hematochezia"
+      - "GI blood"
+      - "bloody bowel"
+  low:
+    partials:
+      # --- original ---
+      - "blood in stool"
+      - "dark stool"
+      - "rectal bleeding"
+      # --- expanded ---
+      - "hematemesis"
+      - "hematochezia"
+      - "melena"
+      - "GI bleed"
+      - "GI bleeding"
+      - "GI hemorrhage"
+      - "upper GI bleed"
+      - "lower GI bleed"
+      - "gastrointestinal bleed"
+      - "gastrointestinal hemorrhage"
+      - "rectal blood"
+      - "bloody emesis"
+      - "coffee ground emesis"
+      - "occult blood"
+      - "fecal blood"
+      - "varices bleeding"
+      - "esophageal bleed"
+      - "anal bleeding"
+
+negation_handling:
+  patterns:
+    # --- original ---
+    - "no blood in stool"
+    - "no vomiting blood"
+    - "stools normal color"
+    # --- expanded ---
+    - "hemorrhoids diagnosed"
+    - "small streak of blood"
+    - "bleeding stopped"
+    - "stool sample normal"
+    - "stool test came back negative"
+    - "no signs of GI bleeding"
+    - "bleeding resolved on its own"
+    - "no active bleeding"
+    - "hemorrhoid flare up"
+    - "just a little hemorrhoid bleeding"
+    - "blood was from a fissure"
+    - "anal fissure causing the blood"
+    - "no more blood in stool"
+    - "colonoscopy was normal"
+    - "occult blood test negative"
+    - "stool guaiac negative"
+    - "no melena or hematemesis"
+    - "dark stool from iron supplements"
+    - "stool dark from medication"
+    - "bleeding from external hemorrhoid only"
+    - "no rectal bleeding"
+    - "bowel movements back to normal"
+    - "no blood noted"
+    - "stools are normal now"
+    - "vomiting but no blood"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_on_medication_class: ["anticoagulants", "NSAIDs", "antiplatelets"]
+      reason: "Medication-related GI bleed risk"
+    - when:
+        patient_has_condition: ["K25.*", "K26.*", "K27.*"]
+      reason: "Known peptic ulcer disease"
diff --git a/list/taxonomy/glucose_out_of_range/flows/clarify.yaml b/list/taxonomy/glucose_out_of_range/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..777b391dd1f6802a0ad76323123f27604f78d18d
--- /dev/null
+++ b/list/taxonomy/glucose_out_of_range/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: glucose_out_of_range
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: glucose_out_of_range_clarify
+      goal: "Ask patient to describe their glucose out of range symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - glucose_out_of_range_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/glucose_out_of_range/flows/escalate_r1.yaml b/list/taxonomy/glucose_out_of_range/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..bb90cc373d97b4176bdb305052e346aada6b0fe8
--- /dev/null
+++ b/list/taxonomy/glucose_out_of_range/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: glucose_out_of_range
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/glucose_out_of_range/flows/handoff.yaml b/list/taxonomy/glucose_out_of_range/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c52ea82c5e59779071ed8b71425777d7b05ebc07
--- /dev/null
+++ b/list/taxonomy/glucose_out_of_range/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: glucose_out_of_range
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: glucose_out_of_range_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: glucose_out_of_range_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/glucose_out_of_range/rules.yaml b/list/taxonomy/glucose_out_of_range/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e650c6633d4e12f82391a0c0381a3ab85d83965c
--- /dev/null
+++ b/list/taxonomy/glucose_out_of_range/rules.yaml
@@ -0,0 +1,21 @@
+domain: glucose_out_of_range
+target_risk_class: R1
+
+decision_rules:
+  - id: glucose_out_of_range_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r1
+
+  - id: glucose_out_of_range_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r1
+
+  - id: glucose_out_of_range_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/glucose_out_of_range/triggers.yaml b/list/taxonomy/glucose_out_of_range/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a4fe758c5ebe1a51ce355d2c128bce051017eea0
--- /dev/null
+++ b/list/taxonomy/glucose_out_of_range/triggers.yaml
@@ -0,0 +1,34 @@
+domain: glucose_out_of_range
+priority: 40
+
+lexical_signals:
+  high:
+    phrases:
+      - "blood sugar staying above 300"
+      - "glucose readings consistently high"
+      - "sugar won't come down to normal"
+      - "blood sugar all over the place"
+      - "glucose persistently elevated"
+      - "blood sugar out of range for days"
+    regex:
+      - "(blood\\s+sugar|glucose).*(above\\s+[23]\\d{2}|out\\s+of\\s+range|persistently)"
+  medium:
+    phrases:
+      - "blood sugar readings are high"
+      - "sugar above normal range"
+      - "glucose not well controlled"
+      - "sugar running higher than target"
+      - "blood sugar fluctuating a lot"
+  low:
+    partials:
+      - "blood sugar"
+      - "glucose"
+      - "sugar levels"
+      - "A1C"
+
+negation_handling:
+  patterns:
+    - "blood sugar normal"
+    - "glucose controlled"
+    - "sugar in range"
+  action: downgrade_confidence
diff --git a/list/taxonomy/heart_failure_worsening/flows/clarify.yaml b/list/taxonomy/heart_failure_worsening/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..573104168682696f5c8f441a0b6a00aecacbb697
--- /dev/null
+++ b/list/taxonomy/heart_failure_worsening/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: heart_failure_worsening
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: heart_failure_worsening_clarify
+      goal: "Ask patient to describe their heart failure worsening symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - heart_failure_worsening_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/heart_failure_worsening/flows/escalate_r2.yaml b/list/taxonomy/heart_failure_worsening/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..971d7b905624163a2719f3e82a7b94aca3d4596d
--- /dev/null
+++ b/list/taxonomy/heart_failure_worsening/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: heart_failure_worsening
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/heart_failure_worsening/flows/handoff.yaml b/list/taxonomy/heart_failure_worsening/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4043cf16546af5cffa08a51f4f35fbaa527447f4
--- /dev/null
+++ b/list/taxonomy/heart_failure_worsening/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: heart_failure_worsening
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: heart_failure_worsening_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: heart_failure_worsening_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/heart_failure_worsening/flows/safety_screen.yaml b/list/taxonomy/heart_failure_worsening/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0af2ca15bdce78b8bbf13277111958a1c8837661
--- /dev/null
+++ b/list/taxonomy/heart_failure_worsening/flows/safety_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: safety_screen
+type: screening
+domain: heart_failure_worsening
+
+required_slots:
+  - weight_change
+  - edema_severity
+  - breathing_status
+  - activity_tolerance
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "weight change"
+        - "edema severity"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - weight_change
+      - edema_severity
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "breathing status"
+        - "activity tolerance"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - breathing_status
+      - activity_tolerance
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/list/taxonomy/heart_failure_worsening/rules.yaml b/list/taxonomy/heart_failure_worsening/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..15a3653bbb2ee09f154d669e2fba7aa3356e5adc
--- /dev/null
+++ b/list/taxonomy/heart_failure_worsening/rules.yaml
@@ -0,0 +1,27 @@
+domain: heart_failure_worsening
+target_risk_class: R2
+
+decision_rules:
+  - id: heart_failure_worsening_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: heart_failure_worsening_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: heart_failure_worsening_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: heart_failure_worsening_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/heart_failure_worsening/triggers.yaml b/list/taxonomy/heart_failure_worsening/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d6b0e25c1e49692ec1bd83dd1b5174ec41f9f01d
--- /dev/null
+++ b/list/taxonomy/heart_failure_worsening/triggers.yaml
@@ -0,0 +1,183 @@
+domain: heart_failure_worsening
+priority: 74
+
+lexical_signals:
+  high:
+    phrases:
+      - 'can''t lie flat to breathe'
+      - 'legs swelling up rapidly'
+      - 'gaining weight rapidly and short of breath'
+      - 'paroxysmal nocturnal dyspnea'
+      - 'waking up gasping for air'
+      - 'heart failure getting worse'
+      - 'short of breath and legs swelling'
+      - 'can''t breathe lying down'
+      - 'feet are really swollen and I''m short of breath'
+      - 'gained 5 pounds in two days'
+      - 'ankles are huge and I can''t catch my breath'
+      - 'heart failure flare up'
+      - 'legs like tree trunks and breathing is terrible'
+      - 'had to sleep sitting in a chair because I couldn''t breathe'
+      - 'put on half a stone in a week and can''t walk to the toilet'
+      - 'my heart failure is decompensating'
+      - 'fluid overload symptoms getting worse'
+      - 'can''t even walk to the kitchen without stopping for breath'
+      - 'woke up choking and my legs are massive'
+      - 'been told I have heart failure and now my legs are swelling badly'
+    regex:
+      - '(heart\s+failure|CHF).*(worse|worsen|getting|flare|decompens)'
+      - 'can''?t\s+lie\s+flat'
+      - '(short\s+of\s+breath|can''?t\s+breathe).{0,30}(swell|edema|ankle|leg|feet|weight)'
+      - '(swell|edema|ankle|leg|feet).{0,30}(short\s+of\s+breath|can''?t\s+breathe|winded)'
+      - 'gained?\s+\d+\s+(pound|lb|kg|stone).{0,20}(day|week|few|couple)'
+      - '(wak|wake|woke).{0,15}(gasp|can''?t\s+breathe|short\s+of\s+breath|choking)'
+      - '(sleep|slept).{0,15}(chair|sitting|upright|propped).{0,20}(can''?t\s+breathe|breath)'
+      - '(can''?t|unable\s+to).{0,10}(walk|move).{0,20}(breath|wind|puff)'
+      - '(fluid\s+overload|decompens).{0,20}(worse|symptom|getting)'
+      - '(massive|huge|enormous).{0,10}(leg|ankle|feet|foot).{0,20}(breath|wind|puff)'
+  medium:
+    phrases:
+      - 'more swollen ankles than before'
+      - 'more short of breath than usual'
+      - 'gained several pounds in a week'
+      - 'increasing leg edema'
+      - 'worsening heart failure symptoms'
+      - 'needing more pillows to sleep'
+      - 'ankles are puffier'
+      - 'shoes don''t fit anymore'
+      - 'rings are tight'
+      - 'feet look like balloons'
+      - 'breathing is harder than usual'
+      - 'winded doing simple things'
+      - 'can''t walk as far as I used to'
+      - 'out of breath more easily'
+      - 'socks leaving marks'
+      - 'legs feel heavy and swollen'
+      - 'pitting when I press'
+      - 'belly feels bloated and tight'
+      - 'weight keeps going up'
+      - 'putting on water weight'
+      - 'sleeping propped up'
+      - 'waking up short of breath'
+      - 'ankles swollen up over my socks'
+      - 'skin feels tight on my legs'
+      - 'can feel the fluid in my legs'
+      - 'calves are rock hard'
+      - 'weighed myself and I am up four pounds'
+      - 'breathing is getting worse day by day'
+      - 'had to stop halfway up the stairs to catch my breath'
+      - 'peeing less than normal'
+      - 'tummy is swollen and hard'
+      - 'can''t bend my ankles properly because of the swelling'
+      - 'went up two notches on my belt'
+      - 'face looks puffy in the morning'
+      - 'fingers are like sausages'
+      - 'clothes are getting tighter but I haven''t been eating more'
+      - 'coughing more when I lie down'
+      - 'pink frothy sputum'
+      - 'wheezing at night in bed'
+      # --- MINIMIZER coverage ---
+      - "swelling, I wouldn't call it swelling, just a little puffiness"
+      - "sleeping on two pillows because it's more comfy"
+      - "shoes feel different sometimes"
+      - "socks leave marks"
+      - "ankles look sort of like they disappeared"
+      - "I notice when I lie flat I feel sort of heavy in my chest"
+      - "gained a little weight but probably just eating more"
+      - "a bit more winded than usual"
+      - "breathing is just a little harder lately"
+    regex:
+      - '(ankle|leg|feet|foot).{0,20}(swell|swollen|puffy|puff|balloon|edema|bigger|heavy)'
+      - '(swell|swollen|puffy|puff).{0,20}(ankle|leg|feet|foot)'
+      - '(shoe|ring|sock|belt|clothes).{0,15}(tight|don''?t\s+fit|leaving\s+mark|cutting|notch)'
+      - '(breath|breathing|winded|breathless).{0,20}(worse|harder|more|easily|usual|than\s+before)'
+      - '(weight|weigh).{0,15}(gain|up|going\s+up|higher|more)'
+      - '(sleep|sleeping|night).{0,20}(prop|pillow|upright|sit\s+up|can''?t\s+lie)'
+      - '(pit|pitting|indent).{0,15}(press|push|finger)'
+      - '(belly|abdomen|stomach|tummy).{0,15}(bloat|tight|distend|swell|hard)'
+      - '(skin|leg|ankle).{0,15}(tight|shiny|stretch|hard).{0,15}(swell|fluid|edema)'
+      - '(pee|urin).{0,15}(less|barely|hardly|not\s+much|reduced)'
+      - '(face|finger|hand).{0,15}(puffy|swell|swollen|sausage|bloat)'
+      - '(cough|wheez).{0,15}(lie|lying|bed|night|flat|down)'
+      - '(pink|frothy|foamy).{0,15}(sputum|phlegm|mucus|cough)'
+      - '(stair|walk|step).{0,15}(stop|rest|breath|wind|puff|gasp)'
+      - '(up|gained)\s+\d+\s+(pound|lb|kg|notch)'
+      - '(fluid|water).{0,15}(retention|retain|holding|build)'
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - '(just|only).{0,10}(a\s+)?(little|bit|slight).{0,10}(puff|swell|bloat|winded|breathless|short of breath|weight|heavier)'
+      - '(shoes?|socks?|rings?|belt).{0,15}(tight|tighter|snug|different|don''t fit|leave marks|digging in)'
+      - '(probably|might be).{0,10}(just|nothing|eating|salt|water|normal).{0,20}(swell|puff|weight|bloat|ankle)'
+      - '(pillow|sleep|lying).{0,15}(extra|two|more|propped|flat).{0,15}(breath|comfy|easier|heavy|chest)'
+      - '(ankle|leg|feet|foot).{0,15}(a\s+)?(bit|little|kind of|sort of).{0,15}(puffy|swollen|big|thick|heavy)'
+  low:
+    partials:
+      - 'heart failure'
+      - 'edema worsening'
+      - 'CHF'
+      - 'orthopnea'
+      - 'swollen ankles'
+      - 'swollen feet'
+      - 'swollen legs'
+      - 'can''t lie flat'
+      - 'gaining weight'
+      - 'water retention'
+      - 'fluid retention'
+      - 'puffy ankles'
+      - 'breathless'
+      - 'winded easily'
+      - 'extra pillows'
+      - 'pitting edema'
+      - 'tight shoes'
+      - 'coughing at night'
+      - 'fluid on lungs'
+      - 'congestion'
+
+negation_handling:
+  patterns:
+    - 'heart failure stable'
+    - 'swelling unchanged'
+    - 'no worsening symptoms'
+    - 'swelling went down'
+    - 'breathing better'
+    - 'weight stable'
+    - 'swelling is the same as usual'
+    - 'ankles have gone down'
+    - 'legs are back to normal'
+    - 'breathing has improved'
+    - 'sleeping flat again'
+    - 'no new swelling'
+    - 'weight has come back down'
+    - 'diuretics are working well'
+    - 'fluid has shifted'
+    - 'walking further than before'
+    - 'heart failure well controlled'
+    - 'no change in weight'
+    - 'swelling comes and goes but is not worse'
+    - 'shoes fit fine now'
+    - 'can lie flat without problems'
+    # --- administrative context (suppress) ---
+    - 'schedule an appointment'
+    - 'follow-up appointment'
+    - 'appointment timing'
+    - 'routine check'
+    - 'just a question'
+    - 'medication refill'
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_has_condition: ["I50.*"]
+        patient_on_medication: ["furosemide", "bumetanide", "torsemide"]
+      reason: "CHF patient on diuretic -- swelling is decompensation signal"
+    - when:
+        patient_has_condition: ["I50.*"]
+        recent_lab:
+          code: "42637-9"
+          value_above: 400
+          within_days: 30
+      reason: "CHF patient with elevated BNP -- fluid overload likely"
+  boost_to_medium:
+    - when:
+        patient_has_condition: ["I50.*"]
+      reason: "CHF history alone raises baseline concern for swelling"
diff --git a/list/taxonomy/hf_stable_monitoring/flows/clarify_hf.yaml b/list/taxonomy/hf_stable_monitoring/flows/clarify_hf.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b7f104bec15e32b48ba20a160889b89a9b21c756
--- /dev/null
+++ b/list/taxonomy/hf_stable_monitoring/flows/clarify_hf.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify_hf
+type: clarification
+domain: hf_stable_monitoring
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: hf_stable_monitoring_clarify
+      goal: "Ask patient to describe what they would like to discuss about their heart failure"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - hf_stable_monitoring_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/hf_stable_monitoring/flows/escalate_hf_monitoring.yaml b/list/taxonomy/hf_stable_monitoring/flows/escalate_hf_monitoring.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7ba38cb8845f5156c3d711ced7f9d05653e390da
--- /dev/null
+++ b/list/taxonomy/hf_stable_monitoring/flows/escalate_hf_monitoring.yaml
@@ -0,0 +1,36 @@
+flow_id: escalate_hf_monitoring
+type: escalation
+domain: hf_stable_monitoring
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: hf_monitoring_escalation_notice
+      goal: "Inform patient their care team will be notified about concerning findings during monitoring"
+      tone: calm_reassuring
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: hf_monitoring_handoff
+      goal: "Schedule nurse callback for concerning monitoring findings"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/hf_stable_monitoring/flows/handoff.yaml b/list/taxonomy/hf_stable_monitoring/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b8976ab251932c0df29717e08f55568e7109889b
--- /dev/null
+++ b/list/taxonomy/hf_stable_monitoring/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: hf_stable_monitoring
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: hf_stable_monitoring_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: hf_stable_monitoring_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/hf_stable_monitoring/flows/monitor_hf_status.yaml b/list/taxonomy/hf_stable_monitoring/flows/monitor_hf_status.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b53cd00f357042cba63086dba47b63e154cf3dca
--- /dev/null
+++ b/list/taxonomy/hf_stable_monitoring/flows/monitor_hf_status.yaml
@@ -0,0 +1,65 @@
+flow_id: monitor_hf_status
+type: screening
+domain: hf_stable_monitoring
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: hf_monitor_step1
+      goal: "Review daily weight trends and fluid intake"
+      tone: warm_professional
+      must_include:
+        - "weight"
+      must_ask:
+        - "What has your weight been like this week? Any changes?"
+        - "How has your fluid intake been?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - daily_weight_trend
+      - fluid_intake
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: hf_monitor_step2
+      goal: "Check exercise tolerance and medication adherence"
+      tone: warm_professional
+      must_include:
+        - "also"
+      must_ask:
+        - "How far can you walk or what activities can you do before feeling short of breath?"
+        - "Have you been taking all your heart medications as prescribed?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - exercise_tolerance
+      - medication_adherence
+
+  - step: 3
+    type: ask
+    response_spec:
+      id: hf_monitor_step3
+      goal: "Screen for any new or worsening symptoms"
+      tone: warm_professional
+      must_include:
+        - "symptoms"
+      must_ask:
+        - "Any new swelling, shortness of breath, or changes you've noticed?"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - symptom_changes
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_hf_monitoring
+  on_low_risk: reassure_hf_stable
+  on_unclear: clarify_hf
diff --git a/list/taxonomy/hf_stable_monitoring/flows/reassure_hf_stable.yaml b/list/taxonomy/hf_stable_monitoring/flows/reassure_hf_stable.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7ea2cec8d5eb870d26887cf223f813d2eb26d5bd
--- /dev/null
+++ b/list/taxonomy/hf_stable_monitoring/flows/reassure_hf_stable.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_hf_stable
+type: resolution
+domain: hf_stable_monitoring
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: hf_stable_reassure
+      goal: "Acknowledge stable heart failure status and reinforce self-monitoring importance"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/hf_stable_monitoring/rules.yaml b/list/taxonomy/hf_stable_monitoring/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7359f763bed3ef457ff987aebc48d0392b740d1b
--- /dev/null
+++ b/list/taxonomy/hf_stable_monitoring/rules.yaml
@@ -0,0 +1,21 @@
+domain: hf_stable_monitoring
+target_risk_class: R1
+
+decision_rules:
+  - id: hf_stable_monitoring_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: monitor_hf_status
+
+  - id: hf_stable_monitoring_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: monitor_hf_status
+
+  - id: hf_stable_monitoring_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify_hf
diff --git a/list/taxonomy/hf_stable_monitoring/triggers.yaml b/list/taxonomy/hf_stable_monitoring/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f66d3aa64dda4ed10a1266f925f67aa68ef6484e
--- /dev/null
+++ b/list/taxonomy/hf_stable_monitoring/triggers.yaml
@@ -0,0 +1,60 @@
+domain: hf_stable_monitoring
+priority: 38
+
+lexical_signals:
+  high:
+    phrases:
+      - "heart failure check-in"
+      - "heart failure follow-up"
+      - "how is my heart failure doing"
+      - "monitoring my heart failure"
+      - "heart failure status check"
+      - "checking on my heart condition"
+    regex:
+      - "heart failure.{0,20}(?:check|follow|monitor|how.{0,5}doing|status)"
+  medium:
+    phrases:
+      - "tracking my weight daily"
+      - "checking my fluid intake"
+      - "monitoring my sodium"
+      - "keeping track of my weight"
+      - "salt intake question"
+      - "fluid diary"
+      - "weighing myself every day"
+      - "weight check for heart failure"
+      - "watching my fluids"
+    regex:
+      - "(?:weight|fluid|salt|sodium).{0,20}(?:check|track|monitor|diary|watch)"
+      - "(?:daily|every day).{0,15}(?:weight|weigh)"
+  low:
+    partials:
+      - "heart follow-up"
+      - "heart appointment"
+      - "heart check"
+      - "heart failure"
+      - "cardiac follow-up"
+      - "heart condition"
+
+negation_handling:
+  patterns:
+    - "heart failure is stable"
+    - "doing well with heart failure"
+    - "no new symptoms"
+    - "weight is stable"
+    - "everything is fine"
+    - "heart failure well controlled"
+    - "no concerns"
+    - "just checking in"
+    # --- administrative context ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_has_condition: ["I50.*"]
+      reason: "Known heart failure patient with monitoring-related language"
diff --git a/list/taxonomy/hf_volume_overload/flows/clarify_hf_volume.yaml b/list/taxonomy/hf_volume_overload/flows/clarify_hf_volume.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..12bb4f0f8480284c3c4f94b7dd8180db5ab05b79
--- /dev/null
+++ b/list/taxonomy/hf_volume_overload/flows/clarify_hf_volume.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify_hf_volume
+type: clarification
+domain: hf_volume_overload
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: hf_volume_overload_clarify
+      goal: "Ask patient to describe their fluid retention symptoms more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - hf_volume_overload_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/hf_volume_overload/flows/escalate_hf_volume.yaml b/list/taxonomy/hf_volume_overload/flows/escalate_hf_volume.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0ab059a7089ec77be597be01fd15e8b47e1b3825
--- /dev/null
+++ b/list/taxonomy/hf_volume_overload/flows/escalate_hf_volume.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_hf_volume
+type: escalation
+domain: hf_volume_overload
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: hf_volume_r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their volume overload symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: hf_volume_r2_handoff
+      goal: "Schedule same-day nurse callback with heart failure volume overload context"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/hf_volume_overload/flows/escalate_r2.yaml b/list/taxonomy/hf_volume_overload/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..fd9708480f642f7c6157941c7a585c237a9122cc
--- /dev/null
+++ b/list/taxonomy/hf_volume_overload/flows/escalate_r2.yaml
@@ -0,0 +1,24 @@
+flow_id: escalate_r2
+type: escalation
+domain: hf_volume_overload
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient about urgency of their heart failure volume overload symptoms and transfer to a clinical team member for same-day evaluation"
+      tone: calm_direct
+      must_include:
+        - "nurse"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably nothing"
+        - "wait and see"
+      max_questions: 0
+
+exit:
+  on_complete: handoff
diff --git a/list/taxonomy/hf_volume_overload/flows/handoff.yaml b/list/taxonomy/hf_volume_overload/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..87f76aa4c3939fe91bc48534287028536851946c
--- /dev/null
+++ b/list/taxonomy/hf_volume_overload/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: hf_volume_overload
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: hf_volume_overload_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: hf_volume_overload_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/hf_volume_overload/flows/reassure_hf_volume.yaml b/list/taxonomy/hf_volume_overload/flows/reassure_hf_volume.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..98a6b9422e623d919a25fadb2727e6a59f8a337a
--- /dev/null
+++ b/list/taxonomy/hf_volume_overload/flows/reassure_hf_volume.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_hf_volume
+type: resolution
+domain: hf_volume_overload
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: hf_volume_reassure
+      goal: "Acknowledge the patient's concern about fluid retention, note that their care team will be informed"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/hf_volume_overload/flows/screen_hf_volume.yaml b/list/taxonomy/hf_volume_overload/flows/screen_hf_volume.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..bf36577efaf50db5176818e40c27217bc722b7b8
--- /dev/null
+++ b/list/taxonomy/hf_volume_overload/flows/screen_hf_volume.yaml
@@ -0,0 +1,52 @@
+flow_id: screen_hf_volume
+type: screening
+domain: hf_volume_overload
+
+required_slots:
+  - weight_change
+  - edema_present
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: hf_volume_screen_step1
+      goal: "Assess weight change and edema severity"
+      tone: calm_urgent
+      must_include:
+        - "weight"
+      must_ask:
+        - "Have you noticed any weight gain in the last few days? How much?"
+        - "How is the swelling in your legs, ankles, or feet?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - weight_change
+      - edema_present
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: hf_volume_screen_step2
+      goal: "Assess orthopnea and medication adherence"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "Can you lie flat to sleep, or do you need extra pillows?"
+        - "Have you been taking your water pill as prescribed?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - orthopnea_status
+      - diuretic_adherence
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_hf_volume
+  on_low_risk: reassure_hf_volume
+  on_unclear: clarify_hf_volume
diff --git a/list/taxonomy/hf_volume_overload/rules.yaml b/list/taxonomy/hf_volume_overload/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..09c0c3a730e7eb93de47f03055e72b96c8909cbb
--- /dev/null
+++ b/list/taxonomy/hf_volume_overload/rules.yaml
@@ -0,0 +1,27 @@
+domain: hf_volume_overload
+target_risk_class: R2
+
+decision_rules:
+  - id: hf_volume_overload_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: screen_hf_volume
+
+  - id: hf_volume_overload_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: screen_hf_volume
+
+  - id: hf_volume_overload_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify_hf_volume
+
+  - id: hf_volume_overload_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_hf_volume
diff --git a/list/taxonomy/hf_volume_overload/triggers.yaml b/list/taxonomy/hf_volume_overload/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e05009b09616185058ce008466eaeaf172754750
--- /dev/null
+++ b/list/taxonomy/hf_volume_overload/triggers.yaml
@@ -0,0 +1,113 @@
+domain: hf_volume_overload
+priority: 75
+
+lexical_signals:
+  high:
+    phrases:
+      - "gained 5 pounds in two days"
+      - "can't lie flat to breathe"
+      - "legs are extremely swollen"
+      - "put on several pounds this week"
+      - "ankles are very puffy and can't breathe"
+      - "feet are extremely swollen and short of breath"
+      - "gained weight rapidly"
+      - "legs swelling up fast"
+      - "can't lay down without gasping"
+      - "woke up gasping and legs are huge"
+      - "fluid building up fast"
+      - "gained 3 kilos overnight"
+      - "extremely puffy and winded"
+      - "legs like tree trunks and breathing hard"
+      - "orthopnea getting worse"
+    regex:
+      - "(?:gained|put on).{0,15}(?:\\d+|several|few).{0,10}(?:pound|lb|kg)"
+      - "can't.{0,15}(?:lie|lay).{0,10}(?:flat|down).{0,15}(?:breathe|breath)"
+      - "(?:leg|ankle|feet|foot).{0,15}(?:very|really|extremely).{0,10}(?:swoll|puff|edema)"
+      - "(?:rapid|fast|sudden).{0,15}(?:weight|swell|fluid|edema)"
+      - "(?:woke|wake).{0,15}(?:gasp|chok).{0,15}(?:leg|ankle|swell)"
+  medium:
+    phrases:
+      - "swelling in my legs"
+      - "ankles are swollen"
+      - "feet are puffy"
+      - "weight is going up"
+      - "need extra pillows to sleep"
+      - "face looks puffy"
+      - "shoes don't fit anymore"
+      - "rings are tight"
+      - "socks leaving deep marks"
+      - "bloated and tight"
+      - "breathing harder when I lie down"
+      - "winded going up stairs"
+      - "peeing less than normal"
+      - "weight keeps creeping up"
+      - "belly feels swollen"
+      - "legs feel heavy"
+      - "can't walk as far"
+      - "propping up to sleep"
+      - "clothes getting tighter"
+      - "pitting when I press my shin"
+      # --- MINIMIZER coverage ---
+      - "just a little puffier than usual"
+      - "shoes feel a bit snug"
+      - "might have gained a pound or two"
+      - "socks are just a little tight"
+      - "sleeping on an extra pillow for comfort"
+    regex:
+      - "(?:swelling|swollen|puffy).{0,15}(?:leg|ankle|feet|face)"
+      - "weight.{0,15}(?:gain|up|increase|higher)"
+      - "(?:pillow|prop).{0,15}(?:sleep|breathe|bed)"
+      - "(?:shoe|ring|sock|belt|clothes).{0,15}(?:tight|don't fit|snug|leave mark)"
+      - "(?:pee|urin).{0,15}(?:less|barely|hardly|not much)"
+      - "(?:belly|abdomen|stomach).{0,15}(?:bloat|tight|distend|swell)"
+      - "(?:just|only).{0,10}(?:a\\s+)?(?:little|bit).{0,10}(?:puff|swell|tight|snug|weight)"
+  low:
+    partials:
+      - "sock tight"
+      - "shoe tight"
+      - "ring tight"
+      - "bloated"
+      - "swollen ankles"
+      - "swollen feet"
+      - "swollen legs"
+      - "weight gain"
+      - "puffy"
+      - "edema"
+      - "fluid retention"
+      - "water retention"
+      - "extra pillows"
+      - "orthopnea"
+
+negation_handling:
+  patterns:
+    - "swelling went down"
+    - "weight is stable"
+    - "ankles back to normal"
+    - "no new swelling"
+    - "breathing fine lying down"
+    - "shoes fit fine"
+    - "swelling is the same"
+    - "legs are back to normal"
+    - "diuretics working well"
+    - "no weight gain"
+    - "weight came back down"
+    - "sleeping flat without problems"
+    - "fluid has resolved"
+    # --- administrative context ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_has_condition: ["I50.*"]
+        patient_on_medication: ["furosemide", "bumetanide", "torsemide"]
+      reason: "Heart failure patient on diuretic with volume overload signals"
+  boost_to_medium:
+    - when:
+        patient_has_condition: ["I50.*"]
+      reason: "Heart failure history raises baseline concern for volume overload"
diff --git a/list/taxonomy/homicidal_ideation/flows/clarify.yaml b/list/taxonomy/homicidal_ideation/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e39bcd1d82195fadb7b02a079b07baaea800e26c
--- /dev/null
+++ b/list/taxonomy/homicidal_ideation/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: homicidal_ideation
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: homicidal_ideation_clarify
+      goal: "Ask patient to describe their homicidal ideation symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - homicidal_ideation_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/homicidal_ideation/flows/escalate_r3.yaml b/list/taxonomy/homicidal_ideation/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3f1f799e09bf884171637be0ecfa104a288d8a12
--- /dev/null
+++ b/list/taxonomy/homicidal_ideation/flows/escalate_r3.yaml
@@ -0,0 +1,38 @@
+flow_id: escalate_r3
+type: escalation
+domain: homicidal_ideation
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Inform patient this requires immediate clinical attention and they will
+      be transferred
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/homicidal_ideation/flows/handoff.yaml b/list/taxonomy/homicidal_ideation/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..051f728fa28fee1245b6a8bc3810ffe838f8f420
--- /dev/null
+++ b/list/taxonomy/homicidal_ideation/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: homicidal_ideation
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: homicidal_ideation_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: homicidal_ideation_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/homicidal_ideation/rules.yaml b/list/taxonomy/homicidal_ideation/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..04fd10c61f2a877b2058cb3ba277d7b0b203dd6e
--- /dev/null
+++ b/list/taxonomy/homicidal_ideation/rules.yaml
@@ -0,0 +1,21 @@
+domain: homicidal_ideation
+target_risk_class: R3
+
+decision_rules:
+  - id: homicidal_ideation_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r3
+
+  - id: homicidal_ideation_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r3
+
+  - id: homicidal_ideation_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/homicidal_ideation/triggers.yaml b/list/taxonomy/homicidal_ideation/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ada7350e38d5a07bc4d6babeb92b09c187ed2f23
--- /dev/null
+++ b/list/taxonomy/homicidal_ideation/triggers.yaml
@@ -0,0 +1,256 @@
+domain: homicidal_ideation
+priority: 93
+
+lexical_signals:
+  high:
+    phrases:
+      - "want to hurt someone"
+      - "going to kill them"
+      - "homicidal thoughts"
+      - "planning to harm someone"
+      - "want to attack someone"
+      - "going to hurt them"
+      - "thinking about hurting someone"
+      - "thinking about hurting my"
+      - "thoughts about hurting someone"
+      - "want to kill"
+      # --- caregiver reports phrases ---
+      - "he said he wants to hurt"
+      - "she said she wants to hurt"
+      - "he threatened to hurt"
+      - "she threatened to hurt"
+      - "he's been threatening"
+      - "she's been threatening"
+      - "my son said he wants to hurt"
+      - "my husband said he wants to hurt"
+      - "my brother said he wants to hurt"
+      - "he's talking about hurting"
+      - "she's talking about hurting"
+      # --- weapon fixation phrases ---
+      - "keeps looking at knives"
+      - "researching guns"
+      - "looking at the gun"
+      - "staring at the knife"
+      - "keeps going to the drawer"
+      - "looking up weapons"
+      - "went to the gun case"
+      - "keeps checking the closet"
+      # --- specific targets phrases ---
+      - "knows where they live"
+      - "knows where he lives"
+      - "knows where she lives"
+      - "following them"
+      - "been following him"
+      - "been following her"
+      - "tracked them down"
+      - "found their address"
+      - "waiting outside their"
+      # --- escalating language phrases ---
+      - "about to snap"
+      - "going to do something"
+      - "gonna do something I can't take back"
+      - "about to lose it"
+      - "going to explode"
+      - "can't hold back anymore"
+      - "running out of patience"
+    regex:
+      - "(want|going|plan|think|thought)\\s+(to|about|of)\\s+(hurt|kill|harm|attack|stab|shoot|strangle)"
+      - "\\b(hurt|kill|harm|attack)\\b.{0,15}\\b(someone|them|him|her|people)\\b"
+      - "(homicid|want.{0,5}(to\\s+)?kill)"
+      - "thinking\\s+about\\s+(hurting|killing|harming|attacking)"
+      - "thoughts?\\s+(about|of)\\s+(hurting|killing|harming)"
+      # --- euphemistic/fragmented violence ---
+      - "(about|of)\\s+harming\\s+(someone|him|her|them|my|a person)"
+      - "(smash|bash|crack|crush).{0,15}(head|skull|face)"
+      - "(make|stop).{0,10}(him|her|them)\\s+(stop|shut|not)\\s+(breath|living|exist)"
+      - "shut\\s+(him|her|them)\\s+up\\s+(for\\s+good|permanently|forever)"
+      - "doing\\s+something\\s+to\\s+(shut|stop|end|silence|get rid)"
+      - "picture\\s+(hurting|hitting|killing|stabbing|choking)"
+      # --- caregiver reports regex ---
+      - "(he|she|my\\s+(son|daughter|husband|wife|brother|sister|nephew|uncle|father|mother))\\s+(said|says|told|keeps\\s+saying|been\\s+saying|mentioned|admitted).{0,30}(want|wants|going|gonna|threatened?).{0,20}(to\\s+)?(hurt|kill|harm|attack)"
+      - "(he|she|they)'?(s|ve)?\\s+(been\\s+)?(threatening|talking\\s+about\\s+hurt|talking\\s+about\\s+kill|making\\s+threats)"
+      - "(my\\s+)?(son|daughter|husband|wife|brother|sister|nephew|uncle|father|mother).{0,30}(threatening|wants?\\s+to\\s+(hurt|kill|harm))"
+      # --- weapon fixation regex ---
+      - "(keep|keeps|kept|been)\\s+(looking|staring|going|checking).{0,15}(at\\s+)?(the\\s+)?(knife|knives|gun|weapon|drawer|closet|cabinet|lockbox)"
+      - "(research|look|search)\\w*\\s+(up|for|into).{0,15}(gun|weapon|knife|firearm|ammunition)"
+      - "(went|goes|going)\\s+(to|for|toward|into)\\s+(the\\s+)?(gun|weapon|knife).{0,10}(case|drawer|cabinet|closet|safe)"
+      - "(staring|looking|glancing)\\s+at\\s+(the\\s+)?(knife|gun|weapon|bat|hammer|tool)"
+      # --- specific targets regex ---
+      - "(know|knows|found|got|has).{0,15}(where|their|his|her).{0,10}(live|address|house|apartment|work)"
+      - "(follow|following|followed|tracking|stalking|watching).{0,15}(them|him|her|the\\s+(neighbor|coworker|boss|ex))"
+      - "(wait|waiting|waited)\\s+(outside|near|for|by).{0,20}(their|his|her|the)"
+      - "(found|looked\\s+up|tracked).{0,15}(address|where|location|house)"
+      # --- escalating language regex ---
+      - "(about\\s+to|going\\s+to|gonna|might)\\s+(snap|explode|lose\\s+it|do\\s+something|blow)"
+      - "(can'?t|won'?t)\\s+(hold|control|stop).{0,15}(back|myself|anymore|any\\s+longer)"
+      - "(running|ran)\\s+out\\s+of\\s+(patience|control|restraint)"
+      - "(losing|lost)\\s+(my\\s+)?(grip|control|patience|mind)"
+      - "do\\s+something\\s+(I|that).{0,20}(regret|can'?t\\s+take\\s+back|irreversible)"
+  medium:
+    phrases:
+      - "feel like I could hurt someone"
+      - "violent thoughts"
+      - "want to harm others"
+      - "losing control of anger"
+      - "I keep seeing his face and I get this heat"
+      - "intrusive angry thoughts"
+      - "can't stop thinking about violence"
+      - "fantasizing about hurting"
+      - "want to beat them up"
+      - "snap at someone"
+      - "terrified I'll do something irreversible"
+      - "scared I'll do something I can't take back"
+      - "worried I'll snap"
+      - "thoughts about getting what he deserves"
+      - "thoughts about getting what she deserves"
+      - "I keep looking at the drawer"
+      # --- euphemistic / conditional / third-person ---
+      - "about to snap"
+      - "runs scenarios in my head"
+      - "pressure valve is about to blow"
+      - "showing them"
+      - "make them pay"
+      - "teach them a lesson"
+      - "getting darker"
+      - "they deserve what's coming"
+      - "someone needs to pay"
+      - "know where they live"
+      - "been following them"
+      - "been watching them"
+      - "I keep picturing it"
+      - "can't get the image out of my head"
+      - "the thoughts won't stop"
+      - "I see red when I think about"
+      - "hands shake when I think about"
+      # --- from missed scenarios analysis ---
+      - "harming someone specific"
+      - "worried about my control"
+      - "I picture hurting him"
+      - "I could smash his head"
+      - "make him stop breathing"
+      - "got scared of myself"
+      - "scared I'm gonna mess up and somebody's gonna get hurt"
+      - "I might swing without thinking"
+      - "thought about specific ways"
+      - "various scenarios"
+      - "chemical compounds and their effects"
+      - "looking up things online"
+      - "looking up weapons"
+      - "drew disturbing pictures"
+      - "he said he wanted to hurt"
+      - "she said she wanted to hurt"
+      - "think about going over there"
+      - "think about hitting him"
+      - "think about hitting her"
+      - "intrusive thoughts"
+      # --- Phase 4: expanded patterns for missed scenarios ---
+      - "thinking about what if they weren't around"
+      - "looking up where they live"
+      - "thoughts getting darker"
+      - "more detailed thoughts"
+      - "can't stop thinking about hurting"
+    regex:
+      - "(hurt|kill|harm|attack).{0,15}(my|that|this)"
+      - "(violen|aggressi).{0,20}(thought|urge|impuls|fantasi)"
+      - "(losing|lost)\\s+control.{0,15}(anger|rage|temper)"
+      - "(snap|explode|blow up|lash out).{0,20}(at|on)\\s+(someone|them|him|her|people)"
+      - "(thought|think|plan).{0,20}(wait|follow|find|confront).{0,20}(him|her|them|coworker|boss|neighbor)"
+      - "(handgun|gun|weapon|knife|firearm).{0,30}(lockbox|drawer|cabinet|closet|car|keep|looking|think)"
+      # --- from missed scenarios analysis ---
+      - "(bad|scary|dark|disturbing|concerning)\\s+(thoughts?|ones?)\\s+(about|lately|regarding)"
+      - "(picture|imagine|visualize|see)\\s+(myself\\s+)?(hurting|hitting|choking|stabbing|killing|punching)"
+      - "(swing|hit|punch|attack)\\s+(without\\s+thinking|on\\s+impulse|before\\s+I)"
+      - "(scared|afraid|worried|terrified)\\s+(of\\s+)?(myself|what I might|I'll|I might)"
+      - "doing\\s+something\\s+to\\s+(him|her|them|my|someone)"
+      - "(I\\s+)?think\\s+about\\s+(hitting|hurting|harming|going after|going over)"
+      - "(thoughts|thinking).{0,20}(getting\\s+more|more\\s+frequent|more\\s+detailed|more\\s+intense|won't\\s+stop)"
+      - "(box\\s+cutter|hammer|metal\\s+pipe|baseball\\s+bat|bat).{0,30}(work|tool|truck|just|it's)"
+      - "(he|she)\\s+said.{0,15}(wanted?\\s+to\\s+)?(hurt|harm|kill)"
+      - "(do|did)\\s+something.{0,15}(irreversible|can't take back|regret|terrible|stupid)"
+      - "(terrified|scared|worried|afraid).{0,20}(snap|hurt|do something|lose control|go off)"
+      # --- euphemistic intent ---
+      - "(fantasiz|dream|think)\\w*\\s+(about|of)\\s+(hurt|harm|kill|attack|get)"
+      # --- conditional threat ---
+      - "(about to|going to|might)\\s+(snap|explode|lose it|do something)"
+      # --- weapon fixation ---
+      - "(stared at|looking at|keep looking at)\\s+(the |a )?(knife|gun|weapon|drawer|bat)"
+      # --- third-person caregiver report ---
+      - "(he|she|they|my)\\s+(keeps?|been)\\s+(talking about|saying|threatening)"
+      # --- making them pay / deserve ---
+      - "(make|teach|show)\\s+(them|him|her)\\s+(a lesson|what|pay)"
+      - "(deserve|coming to)\\s+(them|him|her|what)"
+      # --- Phase 4: expanded patterns for missed scenarios ---
+      - "(think|thinking).{0,40}(what|what if).{0,30}(weren't|gone|wasn't).{0,40}(around|here|alive)"
+      - "(looked up|looking up|found).{0,30}(where|address).{0,30}(he|she|they|lives?)"
+      - "(getting|more|thoughts).{0,15}(darker|intense|detailed|specific|frequent)"
+      - "(thought|thinking).{0,30}(specific|detailed).{0,20}(way|how|plan)"
+      # --- caregiver interrupted disclosure ---
+      - "(said|saying).{0,20}(wanted?\\s+to|thing about).{0,30}(hurt|harm)"
+      # --- weapons + visual/research ---
+      - "(looking\\s+up|research).{0,15}(weapon|knife|gun).{0,30}(drew|picture|sketch)"
+  low:
+    partials:
+      - "violent urges"
+      - "homicidal"
+      - "rage"
+      - "hurt someone"
+      - "kill someone"
+      - "dark thoughts about"
+      - "intense feelings toward"
+      - "can't stop thinking about them"
+      - "revenge"
+      - "snap"
+      - "lose it"
+
+negation_handling:
+  patterns:
+    - "don't want to hurt anyone"
+    - "not violent"
+    - "no intent to harm"
+    # --- financial/logistics/non-violent context ---
+    - "hurt my budget"
+    - "hurt my routine"
+    - "hurt my schedule"
+    - "harm my routine"
+    - "harm my schedule"
+    - "coverage"
+    - "storage"
+    - "encourage"
+    - "discourage"
+    - "insurance coverage"
+    - "drug coverage"
+    - "copay"
+    - "out of pocket"
+    - "might hurt my"
+    - "could hurt my"
+    - "this hurts my"
+    - "won't kill me"
+    - "it's killing me"
+    - "killing my back"
+    - "killing my budget"
+    # --- pharmacy / substring false-positive context (handled by \b in regex) ---
+    # --- medical pain/appetite context ---
+    - "hurts my appetite"
+    - "kills my appetite"
+    - "hurts to eat"
+    - "hurts to swallow"
+    - "hurts my mouth"
+    - "hurts my throat"
+    - "hurts my stomach"
+    - "hurt the wound"
+    - "hurt the stitches"
+    - "hurt the incision"
+    - "don't want to hurt"
+    - "killing my appetite"
+    - "hurts when I"
+    - "it hurts to"
+    # --- administrative / routine context suppression ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "when can I come in"
+    - "medication refill"
+    - "need a refill"
+    - "routine check"
+    - "just a question"
+    - "appointment timing"
+  action: downgrade_confidence
diff --git a/list/taxonomy/hypertension_uncontrolled/flows/clarify_bp.yaml b/list/taxonomy/hypertension_uncontrolled/flows/clarify_bp.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8e31ce6689d57ad529cfb3c5ace26a8480b20d35
--- /dev/null
+++ b/list/taxonomy/hypertension_uncontrolled/flows/clarify_bp.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify_bp
+type: clarification
+domain: hypertension_uncontrolled
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: hypertension_uncontrolled_clarify
+      goal: "Ask patient to describe their blood pressure concern more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - hypertension_uncontrolled_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/hypertension_uncontrolled/flows/escalate_bp.yaml b/list/taxonomy/hypertension_uncontrolled/flows/escalate_bp.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3cdb2c188419afe81723d9de3149a32b21dfa034
--- /dev/null
+++ b/list/taxonomy/hypertension_uncontrolled/flows/escalate_bp.yaml
@@ -0,0 +1,36 @@
+flow_id: escalate_bp
+type: escalation
+domain: hypertension_uncontrolled
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: bp_escalation_notice
+      goal: "Inform patient their care team will be notified about concerning blood pressure findings"
+      tone: calm_reassuring
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: bp_escalation_handoff
+      goal: "Schedule nurse callback for concerning blood pressure findings"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/hypertension_uncontrolled/flows/escalate_r3.yaml b/list/taxonomy/hypertension_uncontrolled/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a4908f8948db2e5cf7638ec0293c8ec3ebf40f06
--- /dev/null
+++ b/list/taxonomy/hypertension_uncontrolled/flows/escalate_r3.yaml
@@ -0,0 +1,28 @@
+flow_id: escalate_r3
+type: escalation
+domain: hypertension_uncontrolled
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: htn_r3_escalation_notice
+    goal: Instruct patient to call 911 immediately for hypertensive emergency with
+      symptoms
+    tone: calm_urgent
+    must_include:
+    - call 911
+    - emergency
+    - right away
+    - blood pressure
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - wait and see
+    - probably nothing
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+exit:
+  on_complete: end
diff --git a/list/taxonomy/hypertension_uncontrolled/flows/handoff.yaml b/list/taxonomy/hypertension_uncontrolled/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5b5998fd18c68b7c52ead61a732da703640d6a7d
--- /dev/null
+++ b/list/taxonomy/hypertension_uncontrolled/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: hypertension_uncontrolled
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: hypertension_uncontrolled_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: hypertension_uncontrolled_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/hypertension_uncontrolled/flows/monitor_bp.yaml b/list/taxonomy/hypertension_uncontrolled/flows/monitor_bp.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c786f5a64f96f46215c230903b5ac74b311d79bd
--- /dev/null
+++ b/list/taxonomy/hypertension_uncontrolled/flows/monitor_bp.yaml
@@ -0,0 +1,65 @@
+flow_id: monitor_bp
+type: screening
+domain: hypertension_uncontrolled
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: bp_monitor_step1
+      goal: "Review recent blood pressure readings"
+      tone: warm_professional
+      must_include:
+        - "blood pressure"
+      must_ask:
+        - "What have your recent blood pressure readings been?"
+        - "How often have you been checking your blood pressure?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - recent_bp_readings
+      - bp_monitoring_frequency
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: bp_monitor_step2
+      goal: "Screen for symptoms that could indicate hypertensive urgency"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "Are you having any headaches, vision changes, chest pain, or shortness of breath?"
+        - "Have you been taking your blood pressure medication as prescribed?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - bp_symptoms
+      - bp_medication_adherence
+
+  - step: 3
+    type: ask
+    response_spec:
+      id: bp_monitor_step3
+      goal: "Check lifestyle factors affecting blood pressure"
+      tone: warm_professional
+      must_include:
+        - "one more"
+      must_ask:
+        - "Have there been any changes in your diet, salt intake, exercise, or stress levels?"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - lifestyle_factors
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_bp
+  on_low_risk: reassure_bp
+  on_unclear: clarify_bp
diff --git a/list/taxonomy/hypertension_uncontrolled/flows/reassure_bp.yaml b/list/taxonomy/hypertension_uncontrolled/flows/reassure_bp.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..38a5f87f3f5297c5a918eda6eab02da8969ce258
--- /dev/null
+++ b/list/taxonomy/hypertension_uncontrolled/flows/reassure_bp.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_bp
+type: resolution
+domain: hypertension_uncontrolled
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: bp_reassure
+      goal: "Acknowledge blood pressure concern, reinforce monitoring and medication adherence, note care team will be informed"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/hypertension_uncontrolled/rules.yaml b/list/taxonomy/hypertension_uncontrolled/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..2e3fc9fe99bba2bbee6c49a7abe46da7bc58ba46
--- /dev/null
+++ b/list/taxonomy/hypertension_uncontrolled/rules.yaml
@@ -0,0 +1,33 @@
+domain: hypertension_uncontrolled
+target_risk_class: R1
+
+decision_rules:
+  - id: hypertension_uncontrolled_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: monitor_bp
+
+  - id: hypertension_uncontrolled_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: monitor_bp
+
+  - id: hypertension_uncontrolled_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify_bp
+
+  - id: hypertension_uncontrolled_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: hypertension_uncontrolled_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_bp
diff --git a/list/taxonomy/hypertension_uncontrolled/triggers.yaml b/list/taxonomy/hypertension_uncontrolled/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6a0ce6dc9b22388c124a97fa8dd55e5eea606447
--- /dev/null
+++ b/list/taxonomy/hypertension_uncontrolled/triggers.yaml
@@ -0,0 +1,68 @@
+domain: hypertension_uncontrolled
+priority: 41
+
+lexical_signals:
+  high:
+    phrases:
+      - "blood pressure is very high"
+      - "BP reading over 180"
+      - "blood pressure 190 over 100"
+      - "systolic over 180"
+      - "blood pressure dangerously high"
+      - "BP was 200"
+      - "blood pressure spiked"
+    regex:
+      - "(?:blood pressure|bp).{0,15}(?:very high|\\d{3})"
+      - "(?:systolic|top number).{0,15}(?:over|above).{0,10}(?:1[6-9]\\d|[2-9]\\d{2})"
+      - "(?:blood pressure|bp).{0,15}(?:dangerously|extremely|spike)"
+  medium:
+    phrases:
+      - "blood pressure is high"
+      - "BP is elevated"
+      - "blood pressure up"
+      - "headache and high blood pressure"
+      - "vision changes and blood pressure"
+      - "blood pressure not controlled"
+      - "readings have been high"
+      - "pressure keeps going up"
+      - "top number keeps being high"
+      - "blood pressure medication not working"
+      - "BP has been running high"
+      - "blood pressure above normal"
+      - "headache with high BP"
+    regex:
+      - "(?:blood pressure|bp).{0,15}(?:high|elevated|up|above)"
+      - "(?:headache|vision).{0,15}(?:blood pressure|bp)"
+      - "(?:blood pressure|bp).{0,15}(?:not controlled|not working|uncontrolled)"
+      - "(?:reading|number).{0,15}(?:high|elevated|up)"
+  low:
+    partials:
+      - "blood pressure check"
+      - "blood pressure monitor"
+      - "blood pressure reading"
+      - "BP medicine"
+      - "BP medication"
+      - "blood pressure"
+      - "hypertension"
+      - "pressure medication"
+
+negation_handling:
+  patterns:
+    - "blood pressure is normal"
+    - "BP is controlled"
+    - "blood pressure fine"
+    - "readings are normal"
+    - "blood pressure is good"
+    - "BP is within range"
+    - "blood pressure stable"
+    - "medication is working"
+    - "no issues with blood pressure"
+    - "blood pressure under control"
+    # --- administrative context ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+    - "BP medication refill"
+  action: downgrade_confidence
diff --git a/list/taxonomy/medication/flows/adverse_reaction.yaml b/list/taxonomy/medication/flows/adverse_reaction.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a4c35f091584699a400c446ddd1b555e38f6e836
--- /dev/null
+++ b/list/taxonomy/medication/flows/adverse_reaction.yaml
@@ -0,0 +1,36 @@
+flow_id: adverse_reaction
+type: escalation
+domain: medication
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: adverse_reaction_urgent
+      goal: "Acknowledge the reaction and transfer to clinical staff immediately"
+      tone: calm_urgent
+      must_include:
+        - "nurse"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "stop taking"
+        - "diagnos"
+        - "don't worry"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: immediate
+    response_spec:
+      id: adverse_reaction_handoff
+      goal: "Transfer to nurse with adverse reaction context"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/medication/flows/clarify.yaml b/list/taxonomy/medication/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b5284d84a2a5ec0ee7e4768b940384a4ab048ae5
--- /dev/null
+++ b/list/taxonomy/medication/flows/clarify.yaml
@@ -0,0 +1,24 @@
+flow_id: clarify
+type: clarification
+domain: medication
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: medication_clarify
+      goal: "Ask patient to clarify their medication-related concern"
+      tone: gentle_professional
+      must_include:
+        - "medication"
+      must_ask:
+        - "help me understand"
+      must_not:
+        - "diagnos"
+      max_questions: 2
+    collects:
+      - medication_concern_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/medication/flows/refill_request.yaml b/list/taxonomy/medication/flows/refill_request.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ffd1c44c2cd5b206a16cdcae87788bc0875fbcaf
--- /dev/null
+++ b/list/taxonomy/medication/flows/refill_request.yaml
@@ -0,0 +1,43 @@
+flow_id: refill_request
+type: service
+domain: medication
+
+required_slots:
+  - medication_name
+  - pharmacy_preference
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: refill_gather
+      goal: "Gather medication name and pharmacy for refill"
+      tone: helpful_professional
+      must_include:
+        - "medication"
+        - "refill"
+      must_ask:
+        - "which medication"
+        - "pharmacy"
+      must_not:
+        - "diagnos"
+      max_questions: 2
+    collects:
+      - medication_name
+      - pharmacy_preference
+
+  - step: 2
+    type: respond
+    response_spec:
+      id: refill_confirm
+      goal: "Confirm refill request has been submitted"
+      tone: warm_professional
+      must_include:
+        - "refill"
+        - "submitted"
+      must_ask: []
+      must_not: []
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/medication/flows/side_effects.yaml b/list/taxonomy/medication/flows/side_effects.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6a387cc0b792fa7cf8b70c12e26e90d559a8f48c
--- /dev/null
+++ b/list/taxonomy/medication/flows/side_effects.yaml
@@ -0,0 +1,33 @@
+flow_id: side_effects
+type: assessment
+domain: medication
+
+required_slots:
+  - medication_name
+  - side_effect_description
+  - side_effect_severity
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: side_effect_gather
+      goal: "Understand which medication and what side effects the patient is experiencing"
+      tone: empathetic_professional
+      must_include:
+        - "medication"
+        - "experiencing"
+      must_ask:
+        - "which medication"
+        - "describe the side effect"
+      must_not:
+        - "stop taking"
+        - "diagnos"
+      max_questions: 2
+    collects:
+      - medication_name
+      - side_effect_description
+
+exit:
+  on_complete: end
+  on_unclear: clarify
diff --git a/list/taxonomy/medication/rules.yaml b/list/taxonomy/medication/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..070dc855dca10f2e5c27d36c15339f8d35bc86f0
--- /dev/null
+++ b/list/taxonomy/medication/rules.yaml
@@ -0,0 +1,36 @@
+domain: medication
+
+decision_rules:
+  - id: medication_adverse_reaction
+    if:
+      confidence: high
+      slots_present:
+        - adverse_reaction
+    then:
+      flow: adverse_reaction
+
+  - id: medication_side_effects
+    if:
+      confidence: high
+      slots_present:
+        - side_effect_report
+    then:
+      flow: side_effects
+
+  - id: medication_refill_high
+    if:
+      confidence: high
+    then:
+      flow: refill_request
+
+  - id: medication_refill_medium
+    if:
+      confidence: medium
+    then:
+      flow: refill_request
+
+  - id: medication_low
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/medication/triggers.yaml b/list/taxonomy/medication/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ca26c0e29654a6ea469dc2e624878d07479139ae
--- /dev/null
+++ b/list/taxonomy/medication/triggers.yaml
@@ -0,0 +1,66 @@
+domain: medication
+priority: 50
+
+lexical_signals:
+  high:
+    phrases:
+      - "medication refill"
+      - "need a refill"
+      - "ran out of medication"
+      - "side effect"
+      - "adverse reaction"
+      - "allergic reaction to medication"
+    regex:
+      - "(need|want|request)\\s+(a\\s+)?refill"
+      - "side\\s+effect"
+  medium:
+    phrases:
+      - "my prescription"
+      - "my medicine"
+      - "pills"
+      - "feeling sick from medication"
+    partials:
+      - "dosage"
+      - "pharmacy"
+  low:
+    phrases:
+      - "something I'm taking"
+    partials:
+      - "tablet"
+      - "capsule"
+
+negation_handling:
+  patterns:
+    - "no medication issues"
+    - "medications are fine"
+    # --- Phase 5: R1 false escalation reduction ---
+    # Dosage / timing questions
+    - "when should I take"
+    - "what time do I take"
+    - "how many pills"
+    - "instructions say"
+    - "how often do I take"
+    - "with food or without"
+    # Side effect inquiry (not adverse reaction)
+    - "is this a side effect"
+    - "could this be from my medication"
+    - "normal side effect"
+    - "my usual side effect"
+    - "same thing happened before"
+    - "already aware"
+    - "expected side effect"
+    - "common side effect"
+    # Routine / administrative context
+    - "routine medication question"
+    - "medication review"
+    - "checking on my"
+    - "just a question about my medication"
+    - "medication list"
+    - "my pharmacy"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+  action: downgrade_confidence
diff --git a/list/taxonomy/medication_nonadherence/flows/clarify.yaml b/list/taxonomy/medication_nonadherence/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9d8073ff06aa40f901c59ae4326b5cc9a93675bb
--- /dev/null
+++ b/list/taxonomy/medication_nonadherence/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: medication_nonadherence
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: medication_nonadherence_clarify
+      goal: "Ask patient to describe their medication nonadherence symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - medication_nonadherence_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/medication_nonadherence/flows/escalate_r1.yaml b/list/taxonomy/medication_nonadherence/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..2608cbd3e4b009bc99b6003c133c08ed936379f7
--- /dev/null
+++ b/list/taxonomy/medication_nonadherence/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: medication_nonadherence
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/medication_nonadherence/flows/handoff.yaml b/list/taxonomy/medication_nonadherence/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..548b724124286f90509529c65203211cc6889d3f
--- /dev/null
+++ b/list/taxonomy/medication_nonadherence/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: medication_nonadherence
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: medication_nonadherence_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: medication_nonadherence_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/medication_nonadherence/rules.yaml b/list/taxonomy/medication_nonadherence/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8fa784f589143ba2beb0e238f99d09413c691ef2
--- /dev/null
+++ b/list/taxonomy/medication_nonadherence/rules.yaml
@@ -0,0 +1,21 @@
+domain: medication_nonadherence
+target_risk_class: R1
+
+decision_rules:
+  - id: medication_nonadherence_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r1
+
+  - id: medication_nonadherence_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r1
+
+  - id: medication_nonadherence_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/medication_nonadherence/triggers.yaml b/list/taxonomy/medication_nonadherence/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3a8ce05eda21663c917fa2335460a13e5dc903bf
--- /dev/null
+++ b/list/taxonomy/medication_nonadherence/triggers.yaml
@@ -0,0 +1,34 @@
+domain: medication_nonadherence
+priority: 49
+
+lexical_signals:
+  high:
+    phrases:
+      - "stopped taking my medication"
+      - "not taking prescribed medicines"
+      - "decided to quit my medications"
+      - "medication non-adherence"
+      - "refusing to take pills"
+      - "haven't taken medication in days"
+    regex:
+      - "(stopped|quit|not)\\s+tak(ing|e)\\s+(my\\s+)?medic"
+  medium:
+    phrases:
+      - "been skipping doses"
+      - "forgot medication a few times"
+      - "not sure about my medications"
+      - "taking less than prescribed"
+      - "ran out and didn't refill"
+      - "missed several doses"
+  low:
+    partials:
+      - "missed dose"
+      - "medication question"
+      - "skipping pills"
+
+negation_handling:
+  patterns:
+    - "taking all medications"
+    - "medication adherence is good"
+    - "taking as prescribed"
+  action: downgrade_confidence
diff --git a/list/taxonomy/meningitis_signal/flows/clarify.yaml b/list/taxonomy/meningitis_signal/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..98f804e964b91b4978e0b1a2dde81844fe2bd90b
--- /dev/null
+++ b/list/taxonomy/meningitis_signal/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: meningitis_signal
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: meningitis_signal_clarify
+      goal: "Ask patient to describe their meningitis signal symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - meningitis_signal_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/meningitis_signal/flows/escalate_r2.yaml b/list/taxonomy/meningitis_signal/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..70867542df0bc2885fd669cefe7bc915e7192060
--- /dev/null
+++ b/list/taxonomy/meningitis_signal/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: meningitis_signal
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/meningitis_signal/flows/escalate_r3.yaml b/list/taxonomy/meningitis_signal/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..233ac69dd60d893b5878126c8a81eb5b1eae4c9a
--- /dev/null
+++ b/list/taxonomy/meningitis_signal/flows/escalate_r3.yaml
@@ -0,0 +1,27 @@
+flow_id: escalate_r3
+type: escalation
+domain: meningitis_signal
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Instruct patient to call 911 or go to the emergency department immediately
+      for possible meningitis
+    tone: calm_urgent
+    must_include:
+    - call 911
+    - emergency
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably nothing
+    - wait and see
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+exit:
+  on_complete: end
diff --git a/list/taxonomy/meningitis_signal/flows/handoff.yaml b/list/taxonomy/meningitis_signal/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7a9dcaf1c6fb7baeedb0d74299c7b3975e0e26d8
--- /dev/null
+++ b/list/taxonomy/meningitis_signal/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: meningitis_signal
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: meningitis_signal_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: meningitis_signal_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/meningitis_signal/flows/safety_screen.yaml b/list/taxonomy/meningitis_signal/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..67544f3fd2234a2fa77e703523ad7b3f178a5e97
--- /dev/null
+++ b/list/taxonomy/meningitis_signal/flows/safety_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: safety_screen
+type: screening
+domain: meningitis_signal
+
+required_slots:
+  - headache_severity
+  - fever_temperature
+  - neck_stiffness
+  - photophobia
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "headache severity"
+        - "fever temperature"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - headache_severity
+      - fever_temperature
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "neck stiffness"
+        - "photophobia"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - neck_stiffness
+      - photophobia
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/list/taxonomy/meningitis_signal/rules.yaml b/list/taxonomy/meningitis_signal/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d4b1fb8c986fccca1b6f3b4c6a1a46eac049c088
--- /dev/null
+++ b/list/taxonomy/meningitis_signal/rules.yaml
@@ -0,0 +1,33 @@
+domain: meningitis_signal
+target_risk_class: R3
+
+decision_rules:
+  - id: meningitis_signal_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: meningitis_signal_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: meningitis_signal_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: meningitis_signal_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: meningitis_signal_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/meningitis_signal/triggers.yaml b/list/taxonomy/meningitis_signal/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..bd0848680e70b806537524122af5f1319c67ecbf
--- /dev/null
+++ b/list/taxonomy/meningitis_signal/triggers.yaml
@@ -0,0 +1,185 @@
+domain: meningitis_signal
+priority: 73
+
+lexical_signals:
+  high:
+    phrases:
+      # --- original ---
+      - "severe headache with fever and stiff neck"
+      - "meningitis symptoms"
+      - "worst headache with high fever"
+      - "neck is stiff and have fever"
+      - "headache fever and can't bend neck"
+      # --- expanded naturalistic ---
+      - "stiff neck and high fever"
+      - "worst headache of my life with fever"
+      - "can't bend my neck forward and have fever"
+      - "neck stiffness with headache and fever"
+      - "light hurts my eyes and I have a fever"
+      - "rash that doesn't blanch with fever"
+      - "petechial rash with headache"
+      - "terrible headache and my neck won't move"
+      - "fever and my neck is so stiff I can't look down"
+      - "splitting headache with stiff neck and temperature"
+      - "high fever and headache and neck pain"
+      - "purple rash with fever and headache"
+      - "rash that doesn't go away when pressed with fever"
+      - "child has fever and stiff neck and headache"
+      - "baby has bulging fontanelle and fever"
+      - "confusion with fever and stiff neck"
+      - "headache so bad with fever and neck won't bend"
+      - "sensitivity to light with fever and neck stiffness"
+      - "vomiting with headache and stiff neck"
+    regex:
+      # --- original ---
+      - "(headache|neck\\s+stiff).*(fever)"
+      - "(meningitis|meningeal)"
+      # --- expanded ---
+      - "(stiff|rigid)\\s+neck\\s+(and|with)\\s+(high\\s+)?fever"
+      - "worst\\s+headache.*(fever|temperature|temp)"
+      - "can'?t\\s+(bend|move|turn)\\s+(my\\s+)?neck.*(fever|temperature)"
+      - "fever.*(stiff|rigid)\\s+neck"
+      - "fever.*(can'?t\\s+(bend|move|turn))\\s+(my\\s+)?neck"
+      - "(light|bright)\\s+(hurts|bothers|sensitivity).*(fever)"
+      - "(rash|petechiae|purpura)\\s+(that\\s+)?(doesn'?t|does\\s+not|won'?t)\\s+(blanch|fade|go\\s+away).*(fever)"
+      - "(petechial|purpuric|non-blanching)\\s+rash.*(headache|fever)"
+      - "(headache|neck).*(headache|neck).*(fever|temperature)"
+      - "(fever|temperature).*(headache).*(stiff|rigid|neck)"
+      - "(confusion|confused|altered).*(fever).*(neck|headache)"
+      - "(vomiting|nausea).*(headache).*(stiff\\s+neck|neck\\s+stiff)"
+  medium:
+    phrases:
+      # --- original ---
+      - "bad headache and fever"
+      - "stiff neck with headache"
+      - "headache and high temperature"
+      - "neck stiffness and fever"
+      - "photophobia with headache and fever"
+      - "headache with neck pain and fever"
+      # --- expanded naturalistic ---
+      - "severe headache with fever"
+      - "neck pain and can't look down"
+      - "high fever and confused"
+      - "rash spreading with fever"
+      - "headache with stiff neck"
+      - "neck is really stiff and I have a headache"
+      - "headache and neck ache together"
+      - "fever with really bad headache"
+      - "light sensitivity with headache"
+      - "my neck hurts to bend forward"
+      - "fever and a terrible headache"
+      - "throbbing headache with neck stiffness"
+      - "headache and can't tolerate light"
+      - "nauseous with headache and stiff neck"
+      - "neck pain with fever and headache"
+      - "high temperature and very bad headache"
+      - "headache is getting worse with neck pain"
+      - "neck so sore can't look down"
+      - "new rash with fever"
+      - "spots on skin with headache"
+      - "headache and very sensitive to light"
+      - "fever and intense head pain"
+      - "headache and neck won't turn"
+      - "stiff neck since this morning with headache"
+      - "confused with high temperature"
+      - "sleepy and hard to wake with fever"
+      - "irritable with fever and headache"
+      - "rash appeared with a fever"
+      # --- MINIMIZER coverage ---
+      - "just a bad headache and my neck is a bit stiff"
+      - "headache and I feel kind of warm"
+      - "neck is sort of stiff and I have a headache"
+      - "probably just a cold but I have a headache and my neck hurts"
+      - "I've had worse headaches before"
+      - "light is kind of annoying"
+      - "headache isn't that bad, just won't go away"
+      - "felt kind of warm and my head hurts"
+      - "stiff neck and headache but probably just tension"
+      - "head hurts and the light really bothers me"
+      - "neck is a bit sore and I have a headache"
+      - "headache keeps coming back and I feel warm"
+    regex:
+      - "(severe|terrible|bad|awful|intense|worst)\\s+headache\\s+(with|and)\\s+(a\\s+)?(fever|temperature)"
+      - "neck\\s+(pain|ache|stiff|sore)\\s+(with|and)\\s+headache"
+      - "(stiff|rigid|sore)\\s+neck\\s+(with|and)\\s+(a\\s+)?headache"
+      - "(high\\s+)?(fever|temperature)\\s+(and|with)\\s+(confused|confusion|altered)"
+      - "(light|photo)\\s*(phobia|sensitiv).*(headache|head\\s+pain)"
+      - "headache\\s+(and|with)\\s+(can'?t\\s+tolerate|sensitive\\s+to)\\s+light"
+      - "rash\\s+(spread|appear|develop|new).*(fever|temperature)"
+      - "(spots|rash|marks)\\s+(on\\s+)?(skin|body).*(headache|fever)"
+      - "(nauseous|vomiting|nausea)\\s+(with|and)\\s+(headache|stiff\\s+neck)"
+      - "(sleepy|drowsy|lethargic|hard\\s+to\\s+wake).*(fever)"
+      - "(irritable|fussy)\\s+(with|and)\\s+(fever|headache|temperature)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(headache|head\\s+hurts?).{0,25}(neck).{0,15}(a\\s+)?(bit|little|kind of|sort of|stiff|sore|tight)"
+      - "(neck).{0,15}(stiff|sore|tight|hurts).{0,20}(headache|head\\s+hurts|head\\s+is)"
+      - "(headache|head).{0,20}(warm|fever|temperature|feverish).{0,15}(kind of|a bit|little|sort of|feel)"
+      - "(just|only).{0,10}(a\\s+)?(bad|nasty|persistent|annoying).{0,10}(headache|head).{0,20}(neck|stiff|warm|fever)"
+      - "(light|bright|lights?).{0,15}(bother|annoy|hurt|sensitive|can'?t stand).{0,20}(headache|head|fever|warm)"
+      - "(headache).{0,25}(won'?t|doesn'?t|not).{0,10}(go away|let up|quit|stop|ease|improve)"
+      - "(probably|might be).{0,10}(just|nothing|cold|flu|tension|stress).{0,20}(headache|neck|stiff|fever|warm)"
+    partials:
+      - "photophobia with headache"
+      - "neck stiffness"
+      - "headache and fever"
+      - "fever and rash"
+      - "non-blanching rash"
+  low:
+    partials:
+      # --- original ---
+      - "meningitis"
+      - "stiff neck headache"
+      - "nuchal rigidity"
+      # --- expanded ---
+      - "meningeal signs"
+      - "meningeal irritation"
+      - "photophobia"
+      - "kernig sign"
+      - "brudzinski sign"
+      - "lumbar puncture"
+      - "CSF analysis"
+      - "bacterial meningitis"
+      - "viral meningitis"
+      - "aseptic meningitis"
+      - "meningococcal"
+      - "meningococcemia"
+      - "petechiae"
+      - "purpura"
+      - "encephalitis"
+      - "neck rigidity"
+      - "jolt accentuation"
+      - "febrile neck stiffness"
+
+negation_handling:
+  patterns:
+    # --- original ---
+    - "no neck stiffness"
+    - "headache resolved"
+    - "no meningitis signs"
+    # --- expanded ---
+    - "neck stiffness from sleeping wrong"
+    - "tension headache"
+    - "migraine without fever"
+    - "neck strain"
+    - "stiff neck from bad pillow"
+    - "headache but no fever"
+    - "neck pain from arthritis"
+    - "cervical spondylosis causing neck stiffness"
+    - "no fever with headache"
+    - "rash blanches with pressure"
+    - "meningitis ruled out"
+    - "lumbar puncture was normal"
+    - "CSF was clear"
+    - "no meningeal signs"
+    - "headache improving"
+    - "neck stiffness resolving"
+    - "viral illness with headache only"
+    - "muscle tension in neck"
+    - "no photophobia"
+    - "no rash present"
+    - "torticollis causing neck stiffness"
+    - "neck stiff from whiplash"
+    - "afebrile with headache"
+    - "febrile but no neck stiffness"
+    - "headache from sinus congestion"
+  action: downgrade_confidence
diff --git a/list/taxonomy/missed_followup/flows/clarify.yaml b/list/taxonomy/missed_followup/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f9d0bdcc628a9cecdd64c0cf0c77d725c792ef30
--- /dev/null
+++ b/list/taxonomy/missed_followup/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: missed_followup
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: missed_followup_clarify
+      goal: "Ask patient to describe their missed followup symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - missed_followup_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/missed_followup/flows/escalate_r1.yaml b/list/taxonomy/missed_followup/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7601a059b3c13139e7de4c1875a5eb835b819d2e
--- /dev/null
+++ b/list/taxonomy/missed_followup/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: missed_followup
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/missed_followup/flows/handoff.yaml b/list/taxonomy/missed_followup/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3b193a681462dafa78cbe579eb20b121b9cfc5e6
--- /dev/null
+++ b/list/taxonomy/missed_followup/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: missed_followup
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: missed_followup_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: missed_followup_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/missed_followup/rules.yaml b/list/taxonomy/missed_followup/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..66800ee94d904f28c8feda2f9e6ff6d83ef31ebb
--- /dev/null
+++ b/list/taxonomy/missed_followup/rules.yaml
@@ -0,0 +1,21 @@
+domain: missed_followup
+target_risk_class: R1
+
+decision_rules:
+  - id: missed_followup_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r1
+
+  - id: missed_followup_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r1
+
+  - id: missed_followup_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/missed_followup/triggers.yaml b/list/taxonomy/missed_followup/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0b8c5b557022e0b17cb3427a41c8de15e8ca1dfb
--- /dev/null
+++ b/list/taxonomy/missed_followup/triggers.yaml
@@ -0,0 +1,77 @@
+domain: missed_followup
+priority: 48
+
+lexical_signals:
+  high:
+    phrases:
+      - "missed my doctor appointment"
+      - "missed my follow-up appointment"
+      - "couldn't make it to my appointment"
+      - "missed post-surgery checkup"
+      - "skipped my follow-up visit"
+      - "didn't go to my scheduled appointment"
+      - "no-showed my appointment"
+      - "never went to my follow-up"
+      - "didn't make it to the doctor"
+      - "haven't seen the doctor since discharge"
+      - "didn't follow up with my doctor"
+      - "I was supposed to see the doctor but didn't"
+      - "haven't gone back to the doctor"
+    regex:
+      - "miss(ed)?\\s+(my\\s+)?(follow.?up|appointment|checkup|doctor)"
+      - "(didn'?t|never|haven'?t)\\s+(go|gone|been|went|make it)\\s+(to\\s+)?(my\\s+)?(follow.?up|appointment|doctor|checkup)"
+      - "(skip|skipped)\\s+(my\\s+)?(follow.?up|appointment|visit)"
+  medium:
+    phrases:
+      - "need to reschedule follow-up"
+      - "can't make my appointment"
+      - "haven't scheduled follow-up yet"
+      - "going to miss my appointment"
+      - "forgot to schedule follow-up"
+      - "don't have a follow-up scheduled"
+      - "no one told me about a follow-up"
+      - "wasn't sure when to follow up"
+      - "haven't called to schedule"
+      - "don't know when my follow-up is"
+      - "haven't made an appointment yet"
+  low:
+    partials:
+      - "missed appointment"
+      - "follow-up"
+      - "reschedule"
+      - "no appointment"
+      - "haven't scheduled"
+
+negation_handling:
+  patterns:
+    - "went to my appointment"
+    - "follow-up completed"
+    - "appointment kept"
+    # --- active scheduling / wound care context ---
+    - "schedule a follow-up"
+    - "scheduling a follow-up"
+    - "need to schedule a follow-up"
+    - "schedule my follow-up"
+    - "scheduling my follow-up"
+    - "when is my follow-up"
+    - "when's my follow-up"
+    - "follow-up is listed"
+    - "follow-up on"
+    - "my follow-up is"
+    - "follow-up appointment"
+    - "wound care"
+    - "dressing change"
+    - "bandage change"
+    - "stitches"
+    - "wound check"
+    - "might need to reschedule"
+    - "need to reschedule"
+    - "trying to avoid rescheduling"
+    - "want to reschedule"
+    - "reschedule my"
+    - "scheduling"
+    - "schedule an appointment"
+    - "make an appointment"
+    - "need to schedule"
+    - "book an appointment"
+  action: downgrade_confidence
diff --git a/list/taxonomy/new_jaundice/flows/clarify.yaml b/list/taxonomy/new_jaundice/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ba5e04f817e72ad56d7bb66743a7971df13caf3e
--- /dev/null
+++ b/list/taxonomy/new_jaundice/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: new_jaundice
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: new_jaundice_clarify
+      goal: "Ask patient to describe their new jaundice symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - new_jaundice_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/new_jaundice/flows/escalate_r2.yaml b/list/taxonomy/new_jaundice/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f3c8d1438dafd5445e38d44202591b22e3a72f24
--- /dev/null
+++ b/list/taxonomy/new_jaundice/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: new_jaundice
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/new_jaundice/flows/handoff.yaml b/list/taxonomy/new_jaundice/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..053bb46367eff2df52b0e5bd88d819e00521462e
--- /dev/null
+++ b/list/taxonomy/new_jaundice/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: new_jaundice
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: new_jaundice_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: new_jaundice_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/new_jaundice/flows/safety_screen.yaml b/list/taxonomy/new_jaundice/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6a2c798308318c4873957032866ab9491f9899c0
--- /dev/null
+++ b/list/taxonomy/new_jaundice/flows/safety_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: safety_screen
+type: screening
+domain: new_jaundice
+
+required_slots:
+  - jaundice_onset
+  - stool_color
+  - urine_color
+  - abdominal_pain
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "jaundice onset"
+        - "stool color"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - jaundice_onset
+      - stool_color
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "urine color"
+        - "abdominal pain"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - urine_color
+      - abdominal_pain
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/list/taxonomy/new_jaundice/rules.yaml b/list/taxonomy/new_jaundice/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d7f62b64d268dc9bac9097258a7eb879b33b1a9a
--- /dev/null
+++ b/list/taxonomy/new_jaundice/rules.yaml
@@ -0,0 +1,27 @@
+domain: new_jaundice
+target_risk_class: R2
+
+decision_rules:
+  - id: new_jaundice_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: new_jaundice_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: new_jaundice_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: new_jaundice_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/new_jaundice/triggers.yaml b/list/taxonomy/new_jaundice/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..829c216c94bc5b16f9758050126f3aac6ea84e50
--- /dev/null
+++ b/list/taxonomy/new_jaundice/triggers.yaml
@@ -0,0 +1,181 @@
+domain: new_jaundice
+priority: 67
+
+lexical_signals:
+  high:
+    phrases:
+      - "skin turned yellow"
+      - "eyes are yellow"
+      - "new jaundice"
+      - "suddenly jaundiced"
+      - "skin and eyes turning yellow"
+      - "yellow discoloration of skin"
+      - "eyes look kind of yellow"
+      - "eyes look yellow"
+      - "my skin has a yellowish tint"
+      - "whites of my eyes are yellow"
+      - "I look jaundiced"
+      - "someone told me I look yellow"
+      - "my face and eyes turned yellow"
+      - "yellow skin and dark urine"
+      - "eyes are definitely yellow not white"
+      - "skin is yellow and I am itching all over"
+      - "whole body has a yellow tone"
+      - "sclera are yellow"
+      - "jaundiced appearance"
+      - "my baby looks yellow"
+      - "newborn is turning yellow"
+      - "skin yellowing and pale stools"
+      - "dark brown urine and yellow eyes"
+    regex:
+      - "(skin|eyes?)\\s+(turn|are|look|looked?)\\s+(kind\\s+of\\s+)?yellow"
+      - "(new|sudden)\\s+jaundice"
+      - "(stool|poop|bowel).*(light|pale|clay|beige|gray|grey|putty|white)"
+      - "eyes?\\s+(look|looked|seem)\\s+(kinda?|kind\\s+of|sort\\s+of\\s+)?yellow"
+      - "poop\\s+looked?\\s+(really\\s+)?light.*clay"
+      - "stools?\\s+(have\\s+)?been\\s+(weirdly\\s+)?light"
+      - "whites?\\s+(of\\s+)?(my\\s+)?eyes?.*(yellow|gold)"
+      - "sclera.*(yellow|icter)"
+      - "(skin|face|body).*(yellow|jaundic).*(tint|tone|hue|color)"
+      - "(yellow|jaundic).*(skin|face|body|eyes?).*(dark|brown|tea|cola)\\s+(urine|pee)"
+      - "(baby|newborn|infant).*(yellow|jaundic)"
+      - "(yellow|jaundic).*(itch|scratch|pruritus)"
+      - "(someone|wife|husband|friend|coworker|family)\\s+(said|told|noticed).*(yellow|jaundic)"
+      - "whole\\s+body.*(yellow|jaundic)"
+      - "(urine|pee).*(dark|brown|tea|cola).*(eyes?|skin).*(yellow|jaundic)"
+  medium:
+    phrases:
+      - "noticed yellow skin"
+      - "eyes look yellowish"
+      - "skin seems yellow"
+      - "jaundice appearing"
+      - "yellowing of skin or eyes"
+      - "scleral icterus"
+      - "eyes look off"
+      - "pee looks darker"
+      - "urine is dark"
+      - "light-colored stool"
+      - "clay-colored stool"
+      - "eyes looked off"
+      - "belly feels sore under my ribs"
+      - "upper belly pain"
+      - "right side of my upper belly"
+      - "my urine is the color of tea"
+      - "poop has been really pale lately"
+      - "stool is almost white"
+      - "I have been itching everywhere"
+      - "skin is itchy all over for no reason"
+      - "urine looks like dark beer"
+      - "my pee is brown"
+      - "stool floats and is pale"
+      - "color of my skin looks off to me"
+      - "something wrong with the color of my eyes"
+      - "I noticed my skin looks different in the mirror"
+      - "under my tongue looks yellow"
+      - "palms of my hands look yellow"
+      - "itching worse at night"
+      - "belly pain right upper area with yellow skin"
+      - "nauseous and my eyes look yellow"
+      - "lost my appetite and skin looks yellow"
+      - "my wife said I look like a banana"
+    regex:
+      - "eyes?\\s+(look|looked|seem)\\s+(off|tired|weird|strange|different)"
+      - "(pee|urine)\\s+(look|is|seem)s?\\s+(dark|brown|tea|cola)"
+      - "(stool|poop).*(pale|light|weird|clay|gray|grey|putty|beige)"
+      - "(belly|abdomen|side).*(sore|ache|pain|hurt).*rib"
+      - "(sister|brother|wife|husband|partner|coworker|friend)\\s+said\\s+my\\s+eyes"
+      - "can't\\s+unsee\\s+it"
+      - "(mirror|bathroom).*(yellow|off)"
+      - "something.*(off|wrong).*mirror"
+      - "what\\s+I'm\\s+seeing\\s+in\\s+.*mirror"
+      - "don't\\s+like\\s+what.*seeing\\s+in\\s+.*mirror"
+      - "looked?\\s+.?yellow"
+      - "i\\s+look\\s+.?off"
+      - "(look|looking)\\s+(off|yellow|jaundic)"
+      - "ache.*(right\\s+side|under\\s+(the\\s+)?ribs?)"
+      - "(right\\s+side|under\\s+(the\\s+)?ribs?).*(ache|sore|pain|hurt)"
+      - "(coworker|friend|partner).*said.*look.*(off|yellow|weird)"
+      - "look.*(off|yellow|weird).*(lighting|mirror|bathroom)"
+      - "(urine|pee).*(color|colour).*(tea|beer|cola|brown|dark|amber)"
+      - "(stool|poop).*(float|almost\\s+white|chalky)"
+      - "(itch|scratch|pruritus).*(everywhere|all\\s+over|whole\\s+body|no\\s+reason)"
+      - "(nausea|nauseous|appetite|weight).*(yellow|jaundic)"
+      - "(yellow|jaundic).*(nausea|nauseous|appetite|weight)"
+      - "(palm|hand|tongue|gum).*(yellow|jaundic)"
+      - "itch.*(worse|bad).*(night|evening|bed)"
+      - "(belly|abdomen).*(pain|ache|sore).*(yellow|jaundic)"
+      - "(banana|golden|orange).*(skin|color|look)"
+      # --- additional caregiver observation ---
+      - "(noticed|saw|see)\\s+(his|her|my|the)\\s+(skin|eyes|face).{0,15}(yellow|jaundic|different|off)"
+      - "(skin|eyes).{0,15}(look|looks|looking)\\s+(more\\s+)?(yellow|golden|jaundiced)"
+  low:
+    partials:
+      - "jaundice"
+      - "yellow skin"
+      - "icterus"
+      - "yellowing"
+      - "yellow eyes"
+      - "dark urine"
+      - "pale stool"
+      - "clay stool"
+      - "eyes look off"
+      - "skin color off"
+      - "tea colored urine"
+      - "brown urine"
+      - "light poop"
+      - "itching all over"
+      - "yellowish"
+      - "skin tint"
+      - "eyes different"
+      - "pale bowel"
+      - "scleral icterus"
+      - "bilirubin"
+
+negation_handling:
+  patterns:
+    - "no jaundice"
+    - "skin color normal"
+    - "yellowness resolved"
+    - "eyes look normal"
+    - "stool color normal"
+    - "not jaundiced"
+    - "no yellow discoloration"
+    - "eyes are white and clear"
+    - "skin is not yellow"
+    - "urine color is normal"
+    - "stool is normal brown"
+    - "no yellowing of eyes"
+    - "jaundice has resolved"
+    - "bilirubin is normal"
+    - "no itching"
+    - "skin color back to normal"
+    - "eyes cleared up"
+    - "yellow tint went away"
+    - "complexion looks normal"
+    - "no scleral icterus"
+    - "jaundice improving"
+    - "urine is light colored again"
+    - "stool color returned to normal"
+    # --- wound drainage context (R1 wound_concern scenarios) ---
+    - "drainage from wound"
+    - "wound drainage"
+    - "drainage on the bandage"
+    - "drainage on the gauze"
+    - "drainage on the pad"
+    - "yellowish drainage from"
+    - "clear yellow fluid"
+    - "incision drainage"
+    - "wound is draining"
+    - "bandage has drainage"
+    - "wound care"
+    - "dressing change"
+    - "stitches"
+    - "sutures"
+    - "staples"
+    # --- urine color context (R1 post_procedure_incontinence) ---
+    - "urine leakage"
+    - "leaking urine"
+    - "incontinence"
+    - "bladder control"
+    - "urine on pad"
+  action: downgrade_confidence
diff --git a/list/taxonomy/npo_violation/flows/clarify.yaml b/list/taxonomy/npo_violation/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..94e3a270403c7bd0400a4ff4eecf1b857cae7da1
--- /dev/null
+++ b/list/taxonomy/npo_violation/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: npo_violation
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: npo_clarify
+      goal: "Ask patient to describe their eating or drinking concern before surgery"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - npo_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/npo_violation/flows/escalate_r2.yaml b/list/taxonomy/npo_violation/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..02cddf63930f11d16b9f59a7c4afbb54c13b0b97
--- /dev/null
+++ b/list/taxonomy/npo_violation/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: npo_violation
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: npo_r2_escalation_notice
+      goal: "Inform patient that the surgical team will follow up same day about their intake before the procedure"
+      tone: calm_reassuring
+      must_include:
+        - "surgical team"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: surgical_nurse
+    urgency: same_day
+    response_spec:
+      id: npo_r2_handoff
+      goal: "Schedule same-day surgical team callback with NPO violation context"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/npo_violation/flows/escalate_r3.yaml b/list/taxonomy/npo_violation/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ecc6e7be7dedd06dcdb093a0a9b263a00e3b244f
--- /dev/null
+++ b/list/taxonomy/npo_violation/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: npo_violation
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Instruct patient to call 911 immediately and inform them of nurse transfer
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/npo_violation/flows/reassure_low_risk.yaml b/list/taxonomy/npo_violation/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ccf3e6acfc4de512c86c2e726ec2ff5ea2c58130
--- /dev/null
+++ b/list/taxonomy/npo_violation/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: npo_violation
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: npo_reassure
+      goal: "Acknowledge the patient followed their fasting instructions correctly and note their care team will be informed"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/npo_violation/flows/safety_screen.yaml b/list/taxonomy/npo_violation/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..775dd54d7cd94dfc770659685b5126a10ee74512
--- /dev/null
+++ b/list/taxonomy/npo_violation/flows/safety_screen.yaml
@@ -0,0 +1,52 @@
+flow_id: safety_screen
+type: screening
+domain: npo_violation
+
+required_slots:
+  - npo_last_intake_time
+  - npo_intake_type
+  - surgery_scheduled_time
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: npo_screen_step1
+      goal: "Determine what the patient consumed and when"
+      tone: calm_urgent
+      must_include:
+        - "eating"
+      must_ask:
+        - "What did you eat or drink?"
+        - "When was the last time you had anything to eat or drink?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - npo_last_intake_time
+      - npo_intake_type
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: npo_screen_step2
+      goal: "Confirm the scheduled surgery time to assess the NPO window"
+      tone: calm_urgent
+      must_include:
+        - "surgery"
+      must_ask:
+        - "What time is your surgery or procedure scheduled?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 1
+    collects:
+      - surgery_scheduled_time
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_r3: escalate_r3
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_r2
diff --git a/list/taxonomy/npo_violation/rules.yaml b/list/taxonomy/npo_violation/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..cff629ca5fe883fb31d23ce1057c8b139be8b15a
--- /dev/null
+++ b/list/taxonomy/npo_violation/rules.yaml
@@ -0,0 +1,33 @@
+domain: npo_violation
+target_risk_class: R2
+
+decision_rules:
+  - id: npo_violation_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: npo_violation_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: npo_violation_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: npo_violation_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: npo_violation_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/npo_violation/triggers.yaml b/list/taxonomy/npo_violation/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..72bd5b63c14f9271fed31208c44e0dac971064f9
--- /dev/null
+++ b/list/taxonomy/npo_violation/triggers.yaml
@@ -0,0 +1,76 @@
+domain: npo_violation
+priority: 70
+
+lexical_signals:
+  high:
+    phrases:
+      - "had breakfast this morning"
+      - "ate before surgery"
+      - "drank coffee before my procedure"
+      - "had food this morning"
+      - "I ate something"
+      - "had a meal before"
+      - "drank water this morning"
+      - "ate a snack before coming in"
+      - "had juice this morning"
+      - "I just ate"
+      - "had toast and coffee"
+      - "ate lunch before my surgery"
+      - "drank milk this morning"
+      - "had some cereal before coming"
+      - "ate right before coming to the hospital"
+      - "I had eggs this morning"
+      - "chewed some gum this morning"
+      - "drank tea before my procedure"
+    regex:
+      - "(ate|eaten|had|drank|drink|consumed|swallowed).{0,20}(this\\s+morning|before\\s+(surgery|procedure|operation)|before\\s+com)"
+      - "(breakfast|lunch|meal|food|snack|coffee|juice|tea|water|milk).{0,20}(this\\s+morning|before\\s+(surgery|procedure|operation)|today)"
+      - "(this\\s+morning|today).{0,20}(ate|eaten|had|drank|drink|consumed).{0,15}(breakfast|food|meal|snack|coffee)"
+      - "(?<!haven't )(?<!didn't )(?<!not )(ate|eaten|had\\s+food|had\\s+breakfast|had\\s+a\\s+meal).{0,15}(before|prior|today|this\\s+morning)"
+      - "(just|already).{0,10}(ate|eaten|had).{0,15}(food|breakfast|meal|snack|something)"
+      - "(food|drink|coffee|water|juice|tea|milk).{0,15}(before|prior).{0,10}(surgery|procedure|operation|anesthesia)"
+  medium:
+    phrases:
+      - "when was I supposed to stop eating"
+      - "can I eat"
+      - "NPO instructions"
+      - "fasting instructions"
+      - "nothing by mouth question"
+      - "when should I stop eating"
+      - "how long before surgery no food"
+      - "can I drink water before surgery"
+      - "eating and drinking before procedure"
+      - "fasting for surgery"
+      - "not sure about the fasting rules"
+      - "confused about when to stop eating"
+  low:
+    partials:
+      - "fasting"
+      - "empty stomach"
+      - "nothing by mouth"
+      - "NPO"
+      - "stop eating"
+
+negation_handling:
+  patterns:
+    - "haven't eaten"
+    - "nothing to eat"
+    - "fasted since midnight"
+    - "empty stomach"
+    - "no food or drink"
+    - "followed the fasting instructions"
+    - "haven't had anything to eat"
+    - "haven't had anything to drink"
+    - "no food since midnight"
+    - "no water since midnight"
+    - "I fasted"
+    - "nothing by mouth"
+    - "didn't eat anything"
+    - "didn't drink anything"
+    - "stopped eating last night"
+    - "last meal was last night"
+    - "no breakfast this morning"
+    - "skipped breakfast"
+    - "followed NPO instructions"
+    - "stomach is empty"
+  action: downgrade_confidence
diff --git a/list/taxonomy/overdose/flows/clarify.yaml b/list/taxonomy/overdose/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ffeac412a4148eb1bcf30970c637aacb6b3cd06b
--- /dev/null
+++ b/list/taxonomy/overdose/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: overdose
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: overdose_clarify
+      goal: "Ask patient to describe their overdose symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - overdose_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/overdose/flows/escalate_r3.yaml b/list/taxonomy/overdose/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3fb1a49d480a18235618d3be27babc877e1829ed
--- /dev/null
+++ b/list/taxonomy/overdose/flows/escalate_r3.yaml
@@ -0,0 +1,38 @@
+flow_id: escalate_r3
+type: escalation
+domain: overdose
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Inform patient this requires immediate clinical attention and they will
+      be transferred
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/overdose/flows/handoff.yaml b/list/taxonomy/overdose/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..922ed1ae11f4d1f40ab10b4809c3b9283818d329
--- /dev/null
+++ b/list/taxonomy/overdose/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: overdose
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: overdose_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: overdose_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/overdose/flows/reassure_low_risk.yaml b/list/taxonomy/overdose/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ec4b9483625b7b371816189ea6de20abf6c02975
--- /dev/null
+++ b/list/taxonomy/overdose/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: overdose
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: overdose_reassure
+      goal: "Acknowledge the patient's concern about medication, note that their care team will be informed for routine follow-up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/overdose/flows/safety_screen.yaml b/list/taxonomy/overdose/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ac6887ee65f0a0bb771a3e92568baac1a146627c
--- /dev/null
+++ b/list/taxonomy/overdose/flows/safety_screen.yaml
@@ -0,0 +1,54 @@
+flow_id: safety_screen
+type: screening
+domain: overdose
+
+required_slots:
+  - substance_taken
+  - amount_timing
+  - intent
+  - consciousness_level
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: overdose_screen_step1
+      goal: "Determine what substance was taken and when"
+      tone: calm_urgent
+      must_include:
+        - "medication"
+      must_ask:
+        - "Can you tell me what you took or what substance is involved?"
+        - "How much did you take and when?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - substance_taken
+      - amount_timing
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: overdose_screen_step2
+      goal: "Screen for intentionality and current mental status"
+      tone: calm_urgent
+      must_include:
+        - "understand"
+      must_ask:
+        - "Was this accidental, like a mix-up with your medications?"
+        - "How are you feeling right now — are you alert and thinking clearly?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - intent
+      - consciousness_level
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_r3
diff --git a/list/taxonomy/overdose/rules.yaml b/list/taxonomy/overdose/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9b5d544c42aec478dbcf904f193f5061df3037db
--- /dev/null
+++ b/list/taxonomy/overdose/rules.yaml
@@ -0,0 +1,27 @@
+domain: overdose
+target_risk_class: R3
+
+decision_rules:
+  - id: overdose_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: overdose_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: overdose_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: overdose_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
diff --git a/list/taxonomy/overdose/triggers.yaml b/list/taxonomy/overdose/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..00afd8a144506abaa190a4707c5951933c663ebc
--- /dev/null
+++ b/list/taxonomy/overdose/triggers.yaml
@@ -0,0 +1,155 @@
+domain: overdose
+priority: 91
+
+lexical_signals:
+  high:
+    phrases:
+      - "took too many pills"
+      - "overdosed"
+      - "took too much medication"
+      - "drug overdose"
+      - "swallowed a bottle of pills"
+      - "poisoning"
+      - "intentional overdose"
+      - "took a handful of pills"
+      - "took way too many"
+    regex:
+      - "(took|swallowed|ate|ingested)\\s+(too\\s+many|a\\s+bottle|a\\s+handful|way\\s+too)"
+      - "overdos"
+      - "(took|swallowed).{0,20}(pills|medication|meds|tablets).{0,20}(too many|bunch|handful|all)"
+      - "(too many|too much).{0,15}(pills|medication|meds|tablets|dose)"
+      - "(took|taken|swallowed)\\s+more\\s+(pills|meds|medication|tablets).{0,20}than"
+  medium:
+    phrases:
+      - "accidentally took extra dose"
+      - "took wrong medication"
+      - "double dosed accidentally"
+      - "ingested something toxic"
+      - "took someone else's medication"
+      - "mixed up my pills"
+      - "taken too much of my"
+      - "might have taken too much"
+      - "took more than I should have"
+      - "my head feels floaty"
+      - "can't think straight after taking"
+      - "grabbed the wrong bottle"
+      - "took some pills and now I'm foggy"
+      - "took pills and feel weird"
+      # --- vague quantity / euphemistic ---
+      - "took a bunch"
+      - "took more than usual"
+      - "kept taking them"
+      - "shut my brain off"
+      - "wanted to sleep"
+      - "grabbed everything"
+      - "empty bottles"
+      - "found empty"
+      - "stared at the pill bottle"
+      - "looking at my medications"
+      - "counting my pills"
+      - "took them all"
+      - "finished the bottle"
+      - "drank with my pills"
+      - "washed them down with alcohol"
+    regex:
+      - "(took|taken|swallowed).{0,20}(too much|extra|wrong|more than)"
+      - "(pills|medication|meds).{0,20}(mixed\\s+up|wrong\\s+(one|pill|med|bottle)|too\\s+many|too\\s+much)"
+      - "(floaty|woozy|drowsy|sleepy|foggy|fuzzy).{0,30}(pills|medication|meds|took)"
+      - "(pills|medication|meds|took).{0,30}(floaty|woozy|drowsy|sleepy|foggy|fuzzy)"
+      - "(took|taken|grabbed).{0,20}(wrong\\s+bottle|wrong\\s+pills|wrong\\s+meds)"
+      - "(might|may)\\s+have\\s+(taken|swallowed).{0,20}(\\d+|several|multiple|few|bunch)"
+      - "took\\s+(some\\s+)?pills.{0,30}(foggy|fuzzy|weird|off|dizzy|sleepy|drowsy|heart)"
+      - "(pills|meds|medication).{0,30}(beer|alcohol|drink|wine|liquor)"
+      # --- vague quantity ---
+      - "took\\s+(a\\s+)?(bunch|handful|lots?|several|all)\\s+(of\\s+)?(pills|meds|medication|tablets)"
+      # --- substance mixing ---
+      - "(pills?|meds?|medication)\\s+(with|and)\\s+(wine|beer|drink|alcohol|vodka|whiskey)"
+      # --- wine/alcohol + medication combination ---
+      - "(wine|drink|alcohol).{0,30}(medication|meds|pills|double|twice)"
+      # --- uncertain disclosure ---
+      - "(think|maybe|might have)\\s+(took|taken)\\s+(too many|extra|more)"
+      # --- minimizer qualification (downplaying severity) ---
+      - "(took|taken|took some).{0,20}(pills|meds).{0,30}(usual|normally|nothing serious)"
+      # --- intent signals ---
+      - "(wanted|trying)\\s+to\\s+(sleep|not wake|shut|numb|stop feeling)"
+      - "(empty|finished|drank)\\s+(the\\s+)?(bottle|pills|meds|medication)"
+      # --- accidental double-dosing / caregiver report ---
+      - "(took|taken|may have taken).{0,15}(twice|them twice|double|two doses|his meds twice|her meds twice)"
+      - "pill\\s+organizer.{0,15}(empty|was empty|gone)"
+      - "(re-?dosed|re-?dose|dosed\\s+(himself|herself|again|twice))"
+      - "(nodding|nods)\\s+off"
+      - "(breathing|breaths?).{0,15}(slow|shallow|barely|labored|weak|faint)"
+      - "(slur|slurring|slurred).{0,15}(speech|words|mid-?sentence|off)"
+      - "(can'?t|couldn'?t)\\s+(stay\\s+awake|keep\\s+(his|her|my)\\s+eyes)"
+      - "(drifts?|drift(s|ed|ing))\\s+(off|away|in and out)"
+      # --- pediatric ingestion ---
+      - "(child|baby|toddler|kid|grandbaby|grandson|granddaughter).{0,30}(got into|ate|swallowed|took|found)"
+      - "(got|gotten)\\s+into\\s+(something|my|the|his|her).{0,15}(pills|meds|medication|medicine|bottle)"
+      - "pill\\s+bottle\\s+(on|was on|found on)\\s+(the\\s+)?floor"
+      - "(pills?|bottle).{0,15}(missing|gone|empty|almost empty|only a few left|less than)"
+      - "(found|saw|noticed).{0,15}(empty|open|spilled).{0,15}(pill|med|bottle|container)"
+  low:
+    partials:
+      - "too much"
+      - "wrong medicine"
+      - "extra pill"
+      - "toxic"
+      - "took too many"
+      - "overdose"
+      - "wrong bottle"
+      - "confused about my pills"
+      - "mixed up my medications"
+
+negation_handling:
+  patterns:
+    - "didn't take too much"
+    - "no overdose"
+    - "took correct dose"
+    - "took the right amount"
+    - "taking as prescribed"
+    - "following the directions"
+    - "confused about the schedule"
+    - "confused about the timing"
+    - "confused about which pill"
+    - "confused about the instructions"
+    - "mixed up the times"
+    - "not sure when to take"
+    - "forgot which one"
+    - "haven't taken too many"
+    - "took my regular dose"
+    - "just the prescribed amount"
+    # --- R1 medication question/inquiry context (suppress) ---
+    - "medication question"
+    - "asking about medication"
+    - "asking about my medication"
+    - "confused about my medication"
+    - "question about my pills"
+    - "question about my meds"
+    - "new prescription"
+    - "new medication"
+    - "just started this medication"
+    - "side effect question"
+    - "is this a side effect"
+    - "could this be a side effect"
+    - "normal side effect"
+    - "expected side effect"
+    - "refill request"
+    - "pharmacy question"
+    - "need a refill"
+    - "prescription refill"
+    - "medication refill"
+    - "how should I take"
+    - "when should I take"
+    - "what time should I take"
+    - "instructions for my medication"
+    - "dosing question"
+    - "dosing schedule"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+    - "medication review"
+    - "med check"
+  action: downgrade_confidence
diff --git a/list/taxonomy/palpitations_dizziness/flows/clarify.yaml b/list/taxonomy/palpitations_dizziness/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d29a17dafd3f6daa9433031b4d2c90fb34160e25
--- /dev/null
+++ b/list/taxonomy/palpitations_dizziness/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: palpitations_dizziness
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: palpitations_dizziness_clarify
+      goal: "Ask patient to describe their palpitations dizziness symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - palpitations_dizziness_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/palpitations_dizziness/flows/escalate_r2.yaml b/list/taxonomy/palpitations_dizziness/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6ace437c61ec9af780a469499345d3cf8fc04c9e
--- /dev/null
+++ b/list/taxonomy/palpitations_dizziness/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: palpitations_dizziness
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/palpitations_dizziness/flows/escalate_r3.yaml b/list/taxonomy/palpitations_dizziness/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..dc1bebd1002603225d1addb55e4bdb1d5f92b685
--- /dev/null
+++ b/list/taxonomy/palpitations_dizziness/flows/escalate_r3.yaml
@@ -0,0 +1,26 @@
+flow_id: escalate_r3
+type: escalation
+domain: palpitations_dizziness
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: palpitations_r3_escalation_notice
+    goal: Instruct patient to call 911 for palpitations with syncope suggesting cardiac
+      arrhythmia
+    tone: calm_urgent
+    must_include:
+    - call 911
+    - emergency
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - wait
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+exit:
+  on_complete: end
diff --git a/list/taxonomy/palpitations_dizziness/flows/handoff.yaml b/list/taxonomy/palpitations_dizziness/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..39841b7eabfc35ab40e6e2cc972b08e250935515
--- /dev/null
+++ b/list/taxonomy/palpitations_dizziness/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: palpitations_dizziness
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: palpitations_dizziness_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: palpitations_dizziness_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/palpitations_dizziness/flows/safety_screen.yaml b/list/taxonomy/palpitations_dizziness/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..40b866921c3bbda0610fd6f448c193288053cf2e
--- /dev/null
+++ b/list/taxonomy/palpitations_dizziness/flows/safety_screen.yaml
@@ -0,0 +1,54 @@
+flow_id: safety_screen
+type: screening
+domain: palpitations_dizziness
+
+required_slots:
+  - palpitation_frequency
+  - dizziness_severity
+  - syncope_history
+  - episode_duration
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "palpitation frequency"
+        - "dizziness severity"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - palpitation_frequency
+      - dizziness_severity
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "syncope history"
+        - "episode duration"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - syncope_history
+      - episode_duration
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/list/taxonomy/palpitations_dizziness/rules.yaml b/list/taxonomy/palpitations_dizziness/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..bf607c313ea6edfd124d4d2130f907eaa1b0f48a
--- /dev/null
+++ b/list/taxonomy/palpitations_dizziness/rules.yaml
@@ -0,0 +1,33 @@
+domain: palpitations_dizziness
+target_risk_class: R2
+
+decision_rules:
+  - id: palpitations_dizziness_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: palpitations_dizziness_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: palpitations_dizziness_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: palpitations_dizziness_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: palpitations_dizziness_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/palpitations_dizziness/triggers.yaml b/list/taxonomy/palpitations_dizziness/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..89d96ada515c0e11cc465be188712c8f36cc96e4
--- /dev/null
+++ b/list/taxonomy/palpitations_dizziness/triggers.yaml
@@ -0,0 +1,192 @@
+domain: palpitations_dizziness
+priority: 75
+
+lexical_signals:
+  high:
+    phrases:
+      # --- ORIGINAL ---
+      - "heart racing and dizzy"
+      - "palpitations with lightheadedness"
+      - "heart pounding and almost fainted"
+      - "irregular heartbeat and dizzy"
+      - "heart fluttering and feel faint"
+      # --- EXPANDED naturalistic ---
+      - "heart is racing and I feel dizzy"
+      - "heart is pounding and I feel like I'm going to faint"
+      - "heart skipping beats and I'm lightheaded"
+      - "heart won't slow down and I feel faint"
+      - "fluttering in my chest and I'm dizzy"
+      - "heart going really fast and the room is spinning"
+      - "dizzy and my heart is pounding out of my chest"
+      - "heart is racing out of nowhere and I can't stand up"
+      - "irregular heartbeat and I almost passed out"
+      - "heart is beating so fast and I'm about to pass out"
+      - "heart is skipping and I feel like I'm going to fall"
+      - "palpitations and almost blacked out"
+      - "heart feels like it's going to explode and I'm dizzy"
+      - "woke up with my heart racing and the room spinning"
+      - "heart rate is really high and I feel unsteady"
+    regex:
+      # --- ORIGINAL ---
+      - "(heart|palpitation).*(dizz|faint|lightheaded)"
+      - "(palpitat|racing).*(dizz|faint)"
+      # --- EXPANDED ---
+      - "heart.{0,15}(racing|pounding|fast|rapid|beating\\s+(so\\s+)?fast).{0,30}(dizz|faint|lightheaded|unsteady|spin|pass\\s+out|black\\s+out)"
+      - "(dizz|faint|lightheaded|unsteady|spin|room\\s+spin).{0,30}heart.{0,15}(racing|pounding|fast|rapid|beating)"
+      - "heart.{0,10}(skip|flutter|irregular|erratic).{0,30}(dizz|faint|lightheaded|unsteady|fall)"
+      - "(skip|flutter|irregular|erratic).{0,10}heart.{0,30}(dizz|faint|lightheaded)"
+      - "heart.{0,10}won'?t\\s+slow\\s+down.{0,20}(dizz|faint|lightheaded|unsteady)"
+      - "(palpitat|racing|pounding).{0,30}(almost|nearly|about\\s+to)\\s+(passed?\\s+out|faint|black)"
+      - "heart.{0,10}(going\\s+to\\s+explode|out\\s+of\\s+(my\\s+)?chest).{0,20}(dizz|faint|lightheaded)"
+      - "woke\\s+up.{0,20}heart\\s+(racing|pounding|fast).{0,20}(dizz|spin|faint)"
+  medium:
+    phrases:
+      # --- ORIGINAL ---
+      - "heart feels like it's racing"
+      - "palpitations and feel faint"
+      - "irregular heartbeat with dizziness"
+      - "heart skipping and lightheaded"
+      - "heart fluttering and unsteady"
+      # --- EXPANDED naturalistic ---
+      - "heart is racing"
+      - "heart is pounding"
+      - "heart skipping beats"
+      - "fluttering in my chest"
+      - "heart won't slow down"
+      - "irregular heartbeat"
+      - "heart going really fast"
+      - "heart beating out of my chest"
+      - "my pulse is really high"
+      - "heart is doing something weird"
+      - "heart feels like it's flipping"
+      - "heart keeps stopping and starting"
+      - "can feel my heart beating really hard"
+      - "my heart won't stop racing"
+      - "heart is going crazy"
+      - "heartbeat feels irregular"
+      - "heart pounding when I'm just sitting"
+      - "random heart racing"
+      - "heart beats really fast then slows down"
+      - "heart rate is really high"
+      - "feel my heart beating in my ears"
+      - "thumping in my chest"
+      - "pounding in my chest"
+      - "heart jumping around"
+      - "I can hear my heartbeat in my ears"
+      - "dizzy and heart racing"
+      - "heart is pounding and I don't feel right"
+      # --- MINIMIZER coverage ---
+      - "heart does this sometimes, no big deal"
+      - "just felt a little off"
+      - "probably just caffeine"
+      - "heart flutters"
+      - "just little skips"
+      - "heart feels funny sometimes"
+      - "a bit lightheaded but probably nothing"
+      - "probably just anxiety"
+      - "heart races sometimes but it passes"
+      # --- additional patterns ---
+      - "heart does this weird thing where it stops"
+      - "feel my pulse in my throat"
+      - "heart goes really fast for no reason"
+    regex:
+      # --- EXPANDED ---
+      - "heart\\s+(is\\s+)?(racing|pounding|beating\\s+(really\\s+)?fast|going\\s+(really\\s+)?fast|hammering|thumping)"
+      - "heart\\s+(is\\s+)?(skipping|fluttering|flipping|jumping|doing\\s+something\\s+weird)"
+      - "heart\\s+(keeps?|won'?t\\s+stop)\\s+(racing|pounding|skipping|beating\\s+fast)"
+      - "(flutter|skip|thump|pound|jump|race).{0,10}(in\\s+)?(my\\s+)?chest"
+      - "heart.{0,10}(out\\s+of|beating\\s+out)\\s+(my\\s+)?chest"
+      - "(can|I)\\s+(feel|hear)\\s+(my\\s+)?heart\\s*(beat|pound|thump|race)"
+      - "heart\\s+(beat|rate|rhythm).{0,10}(irregular|erratic|abnormal|weird|off|fast|high|rapid)"
+      - "(pulse|heart\\s+rate)\\s+(is\\s+)?(really\\s+)?(high|fast|elevated|rapid|\\d{3})"
+      - "heart.{0,10}(going|went)\\s+crazy"
+      - "heart.{0,15}(stop|start).{0,10}(and\\s+)?(start|stop)"
+      - "heart.{0,10}(beats?|goes?)\\s+(really\\s+)?fast\\s+(then|and)\\s+(slow|stop|normal)"
+      - "(random|sudden|out\\s+of\\s+nowhere)\\s+(heart\\s+)?rac(ing|e)"
+      - "heart\\s+(pound|rac|thump).{0,15}(just\\s+)?(sit|rest|lying|lay|stand|still|doing\\s+nothing)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(just|only).{0,10}(a\\s+)?(little|bit|slight).{0,10}(flutter|skip|race|palpit|lightheaded|dizzy|faint)"
+      - "(heart|chest).{0,15}(funny|weird|off|flutter|skip|noticeable).{0,15}(sometimes|occasionally|now and then|kind of|sort of)"
+      - "(probably|might be).{0,10}(just|nothing|caffeine|stress|anxiety|normal).{0,20}(heart|palpit|dizzy|lightheaded|flutter)"
+      - "(lightheaded|dizzy|faint).{0,15}(a\\s+)?(bit|little|kind of|sort of|comes and goes)"
+      # --- Intermittent + vague patterns (R2 recall) ---
+      - "(racing|palpitations|flutter).{0,40}(intermittent|comes and goes|on and off).{0,40}(hard to|can't|difficult).{0,15}(pin down|describe|explain)"
+      - "(heart|pulse).{0,15}(intermittent|sporadic|random).{0,20}(racing|fast|pounding|flutter)"
+      - "(comes and goes|on and off|intermittent).{0,25}(heart|racing|palpitations|flutter)"
+      # --- Caregiver concern patterns ---
+      - "(worried|concerned|noticed).{0,15}(his|her|their|my).{0,10}(heart|pulse).{0,15}(racing|fast|pounding|irregular)"
+      - "(his|her|their).{0,10}(heart).{0,15}(racing|pounding|fast).{0,15}(episodes?|spells?|attacks?)"
+      - "(he|she|they).{0,10}(seems?|looks?|appears?).{0,15}(lightheaded|dizzy|unsteady|faint)"
+      - "(worried|concerned|scared).{0,20}(about|because).{0,15}(heart|palpitations|racing|dizziness)"
+    partials:
+      - "heart going fast"
+      - "heart beating fast"
+      - "heart thumping"
+      - "heart hammering"
+      - "heart doing something weird"
+      - "chest fluttering"
+      - "pulse high"
+  low:
+    partials:
+      # --- ORIGINAL ---
+      - "palpitations"
+      - "heart racing"
+      - "fluttering heart"
+      # --- EXPANDED ---
+      - "heart pounding"
+      - "heart skipping"
+      - "heart fluttering"
+      - "irregular heartbeat"
+      - "rapid heartbeat"
+      - "fast heart rate"
+      - "tachycardia"
+      - "arrhythmia"
+      - "atrial fibrillation"
+      - "afib"
+      - "a-fib"
+      - "heart rhythm"
+      - "heart rate high"
+      - "pulse fast"
+      - "pulse racing"
+      - "skipped beats"
+      - "extra beats"
+      - "PVCs"
+      - "PACs"
+
+negation_handling:
+  patterns:
+    # --- ORIGINAL ---
+    - "no palpitations"
+    - "heart rhythm is fine"
+    - "no dizziness with heart"
+    # --- EXPANDED ---
+    - "no heart racing"
+    - "heart rate is normal"
+    - "heart rate is fine"
+    - "heart rhythm is normal"
+    - "heartbeat is regular"
+    - "heartbeat is normal"
+    - "palpitations stopped"
+    - "palpitations resolved"
+    - "palpitations went away"
+    - "heart not racing anymore"
+    - "heart has calmed down"
+    - "heart slowed down"
+    - "heart is back to normal"
+    - "heart rate came back down"
+    - "no more skipping"
+    - "no more fluttering"
+    - "no irregular heartbeat"
+    - "palpitations much better"
+    - "heart feels fine now"
+    - "heart feels normal"
+    - "pulse is normal"
+    - "no racing heart"
+    - "dizziness gone and heart is fine"
+    - "only when I exercise"
+    - "only with caffeine"
+    - "only after coffee"
+    - "only when I'm anxious"
+    - "goes away when I rest"
+    - "resolved on its own"
+  action: downgrade_confidence
diff --git a/list/taxonomy/panic_crisis/flows/clarify.yaml b/list/taxonomy/panic_crisis/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..87d90cd4b6c7dcc43c88ae1fc3a2ae35198cfeed
--- /dev/null
+++ b/list/taxonomy/panic_crisis/flows/clarify.yaml
@@ -0,0 +1,26 @@
+flow_id: clarify
+type: clarification
+domain: panic_crisis
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: panic_clarify
+      goal: "Gently ask patient to describe their anxiety experience"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "I want to make sure I understand what you're experiencing. Could you describe what's happening?"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "just anxiety"
+      max_questions: 1
+    collects:
+      - panic_clarify_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: escalate_r2
diff --git a/list/taxonomy/panic_crisis/flows/escalate_r2.yaml b/list/taxonomy/panic_crisis/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6d973418d653f9a644faafd990245a8392e9adeb
--- /dev/null
+++ b/list/taxonomy/panic_crisis/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: panic_crisis
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: panic_r2_escalation_notice
+      goal: "Connect patient with mental health crisis support"
+      tone: empathetic
+      must_include:
+        - "support"
+        - "988"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "just anxiety"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: mental_health_professional
+    urgency: same_day
+    response_spec:
+      id: panic_r2_handoff
+      goal: "Transfer to mental health professional"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/panic_crisis/flows/escalate_r3.yaml b/list/taxonomy/panic_crisis/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b12fa12a2f3138b8c172931d3498489d79f5d337
--- /dev/null
+++ b/list/taxonomy/panic_crisis/flows/escalate_r3.yaml
@@ -0,0 +1,38 @@
+flow_id: escalate_r3
+type: escalation
+domain: panic_crisis
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: panic_r3_escalation_notice
+    goal: Possible cardiac event — immediate medical attention
+    tone: calm_urgent
+    must_include:
+    - call 911
+    - right away
+    - chest
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - just anxiety
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: panic_r3_handoff
+    goal: Transfer to clinical nurse for possible cardiac event
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/panic_crisis/flows/safety_screen.yaml b/list/taxonomy/panic_crisis/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..197af2dfc6518574fad791302abb5fbe6e5387c9
--- /dev/null
+++ b/list/taxonomy/panic_crisis/flows/safety_screen.yaml
@@ -0,0 +1,57 @@
+flow_id: safety_screen
+type: screening
+domain: panic_crisis
+
+required_slots:
+  - panic_frequency
+  - somatic_cardiac_crosscheck
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: panic_screen_step1
+      goal: "Assess panic frequency and current episode duration"
+      tone: gentle_professional
+      must_include:
+        - "understand"
+        - "safe"
+      must_ask:
+        - "How often do you experience panic attacks?"
+        - "How long has this current episode been going on?"
+      must_not:
+        - "don't worry"
+        - "diagnos"
+        - "just anxiety"
+        - "all in your head"
+      max_questions: 2
+    collects:
+      - panic_frequency
+      - panic_duration_current
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: panic_screen_step2
+      goal: "Critical cardiac crosscheck and grounding assessment"
+      tone: gentle_professional
+      must_include:
+        - "important"
+      must_ask:
+        - "I need to ask an important question — are you having any actual chest pain or numbness in your arm?"
+        - "Have you been able to try any calming techniques like deep breathing?"
+      must_not:
+        - "don't worry"
+        - "diagnos"
+        - "just anxiety"
+      max_questions: 2
+    collects:
+      - somatic_cardiac_crosscheck
+      - grounding_attempted
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_r2: escalate_r2
+  on_low_risk: escalate_r2
+  on_unclear: escalate_r2
diff --git a/list/taxonomy/panic_crisis/rules.yaml b/list/taxonomy/panic_crisis/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1426bb8b8482372e28d70efee9e17f9bcd5dca38
--- /dev/null
+++ b/list/taxonomy/panic_crisis/rules.yaml
@@ -0,0 +1,33 @@
+domain: panic_crisis
+target_risk_class: R2
+
+decision_rules:
+  - id: panic_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: panic_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: panic_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: panic_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: panic_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/panic_crisis/triggers.yaml b/list/taxonomy/panic_crisis/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..dc90673b58e1fef6dbe681d61efbb8753b948871
--- /dev/null
+++ b/list/taxonomy/panic_crisis/triggers.yaml
@@ -0,0 +1,62 @@
+domain: panic_crisis
+priority: 55
+
+lexical_signals:
+  high:
+    phrases:
+      - "having a panic attack"
+      - "can't breathe from anxiety"
+      - "feel like I'm dying from anxiety"
+      - "I'm having a panic attack right now"
+      - "anxiety is so bad I can't breathe"
+      - "feel like I'm going to die from this anxiety"
+      - "panic attack won't stop"
+    regex:
+      - "(having|in the middle of|going through)\\s+(a\\s+)?panic\\s+attack"
+      - "(can'?t|cannot)\\s+breathe.{0,20}(anxiety|panic|scared|fear)"
+      - "(feel|feels)\\s+like\\s+(I'?m|I am)\\s+(dying|going to die).{0,20}(anxiety|panic)"
+      - "panic\\s+attack.{0,15}(won'?t|will not|doesn'?t|does not)\\s+stop"
+  medium:
+    phrases:
+      - "heart racing and I can't stop"
+      - "walls closing in"
+      - "frozen with fear"
+      - "can't stop shaking from anxiety"
+      - "overwhelming anxiety"
+      - "severe anxiety attack"
+      - "chest tightness from anxiety"
+      - "hyperventilating from anxiety"
+      - "feel like I'm losing control"
+      - "derealization"
+      - "everything feels unreal"
+      - "I think I'm going crazy"
+    regex:
+      - "(heart|pulse)\\s+(racing|pounding|fast).{0,20}(can'?t|won'?t|will not)\\s+stop"
+      - "(walls?|room|world)\\s+(closing|caving|spinning)"
+      - "(frozen|paralyzed|can'?t move)\\s+(with|from|by)\\s+(fear|anxiety|panic|terror)"
+      - "(hyperventilat|can'?t catch my breath).{0,15}(anxiety|panic|fear)"
+      - "(everything|things?)\\s+(feel|feels|seem)\\s+(unreal|fake|dreamlike)"
+      - "(losing|lost)\\s+(control|my mind|it)"
+  low:
+    partials:
+      - "panicking"
+      - "anxiety attack"
+      - "panic attack"
+      - "severe anxiety"
+      - "can't calm down"
+
+negation_handling:
+  patterns:
+    - "panic attack is over"
+    - "feeling calmer now"
+    - "anxiety is getting better"
+    - "panic attack ended"
+    - "used to have panic attacks"
+    - "anxiety is manageable"
+    - "took my anxiety medication"
+    - "medication helped"
+    # Cardiac symptoms — NOT panic, route to chest_pain domain
+    - "chest pain and arm numbness"
+    - "chest pain radiating"
+    - "crushing chest pressure"
+  action: downgrade_confidence
diff --git a/list/taxonomy/persistent_dizziness/flows/clarify.yaml b/list/taxonomy/persistent_dizziness/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..53989bb586b5b1d12fbb080478da116f0b92f73b
--- /dev/null
+++ b/list/taxonomy/persistent_dizziness/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: persistent_dizziness
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: persistent_dizziness_clarify
+      goal: "Ask patient to describe their persistent dizziness symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - persistent_dizziness_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/persistent_dizziness/flows/escalate_r1.yaml b/list/taxonomy/persistent_dizziness/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..96a700d6a865c96bb39f80e038da82521bb4d18b
--- /dev/null
+++ b/list/taxonomy/persistent_dizziness/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: persistent_dizziness
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/persistent_dizziness/flows/handoff.yaml b/list/taxonomy/persistent_dizziness/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..15bb1562177187286b9ef4ce01930c32ed66e2c0
--- /dev/null
+++ b/list/taxonomy/persistent_dizziness/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: persistent_dizziness
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: persistent_dizziness_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: persistent_dizziness_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/persistent_dizziness/rules.yaml b/list/taxonomy/persistent_dizziness/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c9b89fd7c9fdacbfb62fc8a39fa4f95f9136e053
--- /dev/null
+++ b/list/taxonomy/persistent_dizziness/rules.yaml
@@ -0,0 +1,21 @@
+domain: persistent_dizziness
+target_risk_class: R1
+
+decision_rules:
+  - id: persistent_dizziness_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r1
+
+  - id: persistent_dizziness_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r1
+
+  - id: persistent_dizziness_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/persistent_dizziness/triggers.yaml b/list/taxonomy/persistent_dizziness/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1916de22be5a90d5287361cb2ddf9b4bf0cba0f2
--- /dev/null
+++ b/list/taxonomy/persistent_dizziness/triggers.yaml
@@ -0,0 +1,52 @@
+domain: persistent_dizziness
+priority: 43
+
+lexical_signals:
+  high:
+    phrases:
+      - "dizzy all the time"
+      - "constant dizziness"
+      - "vertigo won't go away"
+      - "persistent dizziness for days"
+      - "room keeps spinning"
+      - "dizzy every time I stand up"
+      - "dizziness hasn't stopped"
+      - "the dizziness won't go away"
+      - "been dizzy for days"
+      - "dizzy since I got home"
+      - "still dizzy"
+      - "always lightheaded"
+      - "world is spinning"
+    regex:
+      - "(constant|persistent|chronic|continuous|ongoing)\\s+(dizziness|vertigo)"
+      - "dizzy\\s+(all\\s+the\\s+time|every|since|for\\s+days|since\\s+discharge|won'?t)"
+      - "(room|world)\\s+(keeps?|is|won'?t\\s+stop)\\s+spin"
+      - "(still|always|keeps?)\\s+(dizzy|lightheaded)"
+  medium:
+    phrases:
+      - "been feeling dizzy frequently"
+      - "dizziness comes and goes"
+      - "lightheaded frequently"
+      - "vertigo episodes recurring"
+      - "balance has been off"
+      - "feeling unsteady"
+      - "keep getting dizzy"
+      - "head is spinning"
+      - "everything spins when I stand"
+      - "dizzy when I move"
+      - "lightheaded when I get up"
+  low:
+    partials:
+      - "dizzy"
+      - "dizziness"
+      - "vertigo"
+      - "lightheaded"
+      - "unsteady"
+      - "off-balance"
+
+negation_handling:
+  patterns:
+    - "not dizzy"
+    - "dizziness resolved"
+    - "balance is fine"
+  action: downgrade_confidence
diff --git a/list/taxonomy/persistent_vomiting/flows/clarify.yaml b/list/taxonomy/persistent_vomiting/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..06f9005139ce8ec3f5712f89b52a2c115f06e8e2
--- /dev/null
+++ b/list/taxonomy/persistent_vomiting/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: persistent_vomiting
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: persistent_vomiting_clarify
+      goal: "Ask patient to describe their persistent vomiting symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - persistent_vomiting_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/persistent_vomiting/flows/escalate_r2.yaml b/list/taxonomy/persistent_vomiting/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d9495e0c4ca51248471c797405bb27eeedcfd1db
--- /dev/null
+++ b/list/taxonomy/persistent_vomiting/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: persistent_vomiting
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/persistent_vomiting/flows/handoff.yaml b/list/taxonomy/persistent_vomiting/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..bc5cb39986371952514ada07a8ee229b48bd4902
--- /dev/null
+++ b/list/taxonomy/persistent_vomiting/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: persistent_vomiting
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: persistent_vomiting_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: persistent_vomiting_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/persistent_vomiting/flows/safety_screen.yaml b/list/taxonomy/persistent_vomiting/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..efd8317b1c8910620e5f258729d9b3da1b3daea6
--- /dev/null
+++ b/list/taxonomy/persistent_vomiting/flows/safety_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: safety_screen
+type: screening
+domain: persistent_vomiting
+
+required_slots:
+  - vomiting_frequency
+  - last_kept_fluids
+  - medications_kept_down
+  - associated_symptoms
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "vomiting frequency"
+        - "last kept fluids"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - vomiting_frequency
+      - last_kept_fluids
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "medications kept down"
+        - "associated symptoms"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - medications_kept_down
+      - associated_symptoms
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/list/taxonomy/persistent_vomiting/rules.yaml b/list/taxonomy/persistent_vomiting/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..fb25336f6b766670201acb000e37e28ac71809d3
--- /dev/null
+++ b/list/taxonomy/persistent_vomiting/rules.yaml
@@ -0,0 +1,27 @@
+domain: persistent_vomiting
+target_risk_class: R2
+
+decision_rules:
+  - id: persistent_vomiting_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: persistent_vomiting_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: persistent_vomiting_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: persistent_vomiting_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/persistent_vomiting/triggers.yaml b/list/taxonomy/persistent_vomiting/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..86454d704e1e67ca522ae0d3dfd8fe973c3aaf36
--- /dev/null
+++ b/list/taxonomy/persistent_vomiting/triggers.yaml
@@ -0,0 +1,189 @@
+domain: persistent_vomiting
+priority: 69
+
+lexical_signals:
+  high:
+    phrases:
+      - 'can''t stop vomiting'
+      - 'vomiting all day'
+      - 'can''t keep anything down'
+      - 'persistent vomiting'
+      - 'unable to keep medications down'
+      - 'vomiting blood'
+      - 'been throwing up all day'
+      - 'nothing stays down'
+      - 'puking non-stop'
+      - 'can''t even keep water down'
+      - 'haven''t kept anything down in hours'
+      - 'vomiting for over 24 hours'
+      - 'thrown up everything including my medication'
+      - 'projectile vomiting'
+      - 'vomiting so much I can''t stand up'
+      - 'been sick constantly since yesterday'
+      - 'can''t hold down any fluids at all'
+      - 'my child has been throwing up non-stop'
+      - 'everything I swallow comes right back up'
+      - 'haven''t been able to drink anything all day'
+    regex:
+      - 'can''?t\s+(stop\s+vomiting|keep\s+(anything|food|meds|water|liquid)\s+down)'
+      - 'vomit.{0,15}(all\s+day|won''?t\s+stop|non-?stop|constant|hour)'
+      - '(throw|threw|puking).{0,15}(everything|all\s+day|non-?stop|constant)'
+      - 'nothing\s+(stay|staying|kept)\s+down'
+      - '(been|keep)\s+(throwing\s+up|vomiting|puking)'
+      - 'vomit.{0,15}(blood|red|coffee\s+ground|dark\s+brown)'
+      - '(haven''?t|has\s+not)\s+(kept|held).{0,15}(anything|food|fluid|water|liquid)\s+down'
+      - 'projectile\s+vomit'
+      - '(vomit|throw|sick|puk).{0,15}(over|more\s+than)\s+\d+\s+hour'
+      - '(vomit|throw|sick|puk).{0,15}(since\s+yesterday|since\s+last\s+night|all\s+night)'
+      - 'can''?t\s+(hold|keep)\s+down\s+(any\s+)?fluid'
+  medium:
+    phrases:
+      - 'throwing up repeatedly'
+      - 'vomiting since last night'
+      - 'nausea and vomiting won''t stop'
+      - 'keep throwing up'
+      - 'can''t keep water down'
+      - 'vomiting after every meal'
+      - 'threw up several times'
+      - 'dry heaving'
+      - 'everything comes back up'
+      - 'stomach won''t settle'
+      - 'keeps coming up'
+      - 'bile coming up'
+      - 'even water comes back up'
+      - 'tried crackers and threw them up'
+      - 'sipping and it comes right back'
+      - 'haven''t been able to eat'
+      - 'mouth is so dry from being sick'
+      - 'lips are cracked and I keep vomiting'
+      - 'not peeing much and still throwing up'
+      - 'feeling really weak from vomiting'
+      - 'been sick about ten times today'
+      - 'heaving but nothing comes up anymore'
+      - 'bringing up green stuff'
+      - 'was sick three times in an hour'
+      - 'wretching every few minutes'
+      - 'stomach is in knots and I keep being sick'
+      - 'head is pounding from throwing up so much'
+      - 'eyes are bloodshot from puking'
+      - 'throat is raw from being sick'
+      - 'can only manage tiny sips and those come up too'
+      - 'tried anti-sickness tablets and threw them up'
+      - 'my urine is really dark and I keep being sick'
+      - 'toddler has been sick all morning'
+      - 'diarrhoea and vomiting together'
+      # --- MINIMIZER coverage ---
+      - "I've just been a bit sick"
+      - "it's probably just a bug"
+      - "threw up once or twice, nothing major"
+      - "just a bit nauseous really"
+      - "stomach is a bit off"
+      - "been feeling kind of queasy"
+      - "threw up but I'm probably fine"
+      - "was sick a few times but nothing to worry about"
+      - "just an upset stomach I think"
+      - "a little bit of vomiting, probably something I ate"
+    regex:
+      - '(threw|throw|vomit|puk).{0,20}(multiple|several|many|few)\s+times?'
+      - '(nause|vomit|throw).{0,20}(worse|getting\s+worse|won''?t\s+stop)'
+      - '(food|eat|drink|water|liquid).{0,20}(comes?\s+back|stays?\s+down|keep\s+down)'
+      - 'dry\s+heav'
+      - '(bile|yellow|green).{0,15}(coming|came|com[ei]s?)\s+up'
+      - '(sip|tried|ate).{0,20}(came|comes?|threw|throw).{0,10}(back|up)'
+      - '(mouth|lips|tongue).{0,15}(dry|cracked|parched).{0,20}(sick|vomit|throw)'
+      - '(not|barely|hardly)\s+(pee|urinat).{0,20}(sick|vomit|throw)'
+      - '(weak|shaky|trembly|exhausted).{0,20}(vomit|throw|sick|puk)'
+      - '(sick|vomit|threw\s+up|thrown\s+up).{0,10}\d+\s+times?'
+      - '\d+\s+times?.{0,10}(sick|vomit|threw\s+up|thrown\s+up)'
+      - '(wretch|retch|heav).{0,15}(every|few|couple)\s+(minute|hour)'
+      - '(throat|voice).{0,10}(raw|sore|hoarse).{0,20}(sick|vomit|throw)'
+      - '(anti[- ]?sick|anti[- ]?emetic|ondansetron|cyclizine|metoclopramide).{0,20}(threw|throw|came|come|vomit)'
+      - '(dark|orange|brown)\s+(urine|pee|wee).{0,20}(sick|vomit|throw)'
+      - '(diarrh|diarr).{0,15}(vomit|throw|sick|puk)'
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(just|only).{0,10}(a\\s+)?(little|bit|touch).{0,10}(sick|nause|queasy|vomit)"
+      - "(probably|might be).{0,10}(just|nothing|a bug|food|something I ate).{0,15}(sick|vomit|threw|nause)"
+      - "(threw|throw|thrown|vomit|sick).{0,15}(once|twice|couple|few).{0,15}(nothing|fine|okay|not that bad)"
+      - "(stomach|tummy|belly).{0,10}(a\\s+)?(bit|little|kind of|sort of).{0,10}(off|upset|queasy|unsettled|dodgy)"
+  low:
+    partials:
+      - 'vomiting'
+      - 'throwing up'
+      - 'nausea'
+      - 'emesis'
+      - 'puking'
+      - 'dry heaving'
+      - 'retching'
+      - 'coming back up'
+      - 'being sick'
+      - 'feeling sick'
+      - 'can''t eat'
+      - 'stomach bug'
+      - 'gastro'
+      - 'dehydrated'
+      - 'dark urine'
+      - 'bile'
+      - 'heaving'
+      - 'wretching'
+
+negation_handling:
+  patterns:
+    - 'no vomiting'
+    - 'stopped throwing up'
+    - 'keeping food down'
+    - 'nausea resolved'
+    - 'stomach settled'
+    - 'vomiting stopped'
+    - 'was sick but feeling better now'
+    - 'held down breakfast'
+    - 'kept the water down this time'
+    - 'managed to eat something'
+    - 'anti-sickness tablets are working'
+    - 'only felt nauseous but did not vomit'
+    - 'nausea has passed'
+    - 'stomach has calmed down'
+    - 'able to keep fluids down now'
+    - 'last vomited hours ago and feeling better'
+    - 'tolerating sips of water'
+    - 'no further episodes'
+    - 'eating and drinking normally again'
+    - 'just a bit queasy but not actually sick'
+    # --- poor oral intake / appetite context (R1 suppression) ---
+    - "just not hungry"
+    - "no appetite"
+    - "food doesn't taste good"
+    - "skipping meals"
+    - "forcing myself to eat"
+    - "not eating much"
+    - "appetite is poor"
+    - "don't feel like eating"
+    - "food doesn't appeal"
+    # --- Phase 5: R1 false escalation reduction ---
+    # Appetite / hunger context (not vomiting)
+    - "just not hungry"
+    - "no appetite lately"
+    - "food doesn't taste good"
+    - "lost my appetite"
+    - "appetite has been off"
+    - "don't feel like eating"
+    # Eating habits (without vomiting)
+    - "skipping meals"
+    - "forcing myself to eat"
+    - "eating less than usual"
+    - "not eating as much"
+    - "smaller portions"
+    - "picking at food"
+    # Post-procedure appetite context
+    - "post-surgery appetite"
+    - "recovering appetite"
+    - "appetite improving"
+    - "appetite coming back"
+    - "starting to eat again"
+    # Routine / administrative context
+    - "routine follow-up about eating"
+    - "checking on nutrition"
+    - "nutrition question"
+    - "dietary question"
+    - "eating habits question"
+    - "weight loss follow-up"
+  action: downgrade_confidence
diff --git a/list/taxonomy/phq2_positive/flows/clarify.yaml b/list/taxonomy/phq2_positive/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5344d40c61e8483d9e6461a160dbae1aff74894a
--- /dev/null
+++ b/list/taxonomy/phq2_positive/flows/clarify.yaml
@@ -0,0 +1,26 @@
+flow_id: clarify
+type: clarification
+domain: phq2_positive
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: phq2_clarify
+      goal: "Ask the patient to tell more about how they have been feeling emotionally"
+      tone: warm_empathetic
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "depression"
+        - "PHQ"
+        - "screening"
+      max_questions: 1
+    collects:
+      - phq2_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/phq2_positive/flows/followup_referral.yaml b/list/taxonomy/phq2_positive/flows/followup_referral.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..30dd634b780dfe6d4477efba068c170f43711e58
--- /dev/null
+++ b/list/taxonomy/phq2_positive/flows/followup_referral.yaml
@@ -0,0 +1,25 @@
+flow_id: followup_referral
+type: resolution
+domain: phq2_positive
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: phq2_followup_referral
+      goal: "Thank the patient for sharing and inform them their care team will follow up. Do NOT reveal any score or clinical interpretation."
+      tone: warm_empathetic
+      must_include:
+        - "care team"
+        - "thank you for sharing"
+      must_not:
+        - "score"
+        - "PHQ"
+        - "depression"
+        - "elevated"
+        - "positive"
+        - "screening result"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/phq2_positive/flows/phq2_screen.yaml b/list/taxonomy/phq2_positive/flows/phq2_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..82c35d41c39122f2f321e8c2e2cf3128409d1115
--- /dev/null
+++ b/list/taxonomy/phq2_positive/flows/phq2_screen.yaml
@@ -0,0 +1,52 @@
+flow_id: phq2_screen
+type: screening
+domain: phq2_positive
+
+required_slots:
+  - phq2_interest
+  - phq2_mood
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: phq2_screen_step1
+      goal: "Administer the first PHQ-2 item: assess loss of interest or pleasure over the past two weeks"
+      tone: warm_empathetic
+      must_include:
+        - "past couple of weeks"
+      must_ask:
+        - "Over the past two weeks, how often have you had little interest or pleasure in doing things?"
+      must_not:
+        - "depression score"
+        - "PHQ"
+        - "screening tool"
+        - "test"
+      max_questions: 1
+    collects:
+      - phq2_interest
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: phq2_screen_step2
+      goal: "Administer the second PHQ-2 item: assess feeling down, depressed, or hopeless over the past two weeks"
+      tone: warm_empathetic
+      must_include:
+        - "past couple of weeks"
+      must_ask:
+        - "And over the past two weeks, how often have you felt down, depressed, or hopeless?"
+      must_not:
+        - "depression score"
+        - "PHQ"
+        - "screening tool"
+        - "test"
+      max_questions: 1
+    collects:
+      - phq2_mood
+
+exit:
+  on_complete: evaluate_concern
+  on_concern: followup_referral
+  on_low_risk: followup_referral
+  on_unclear: followup_referral
diff --git a/list/taxonomy/phq2_positive/rules.yaml b/list/taxonomy/phq2_positive/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..02cd068cfdce3097eb0d2b2950a66bcf24c543a3
--- /dev/null
+++ b/list/taxonomy/phq2_positive/rules.yaml
@@ -0,0 +1,27 @@
+domain: phq2_positive
+target_risk_class: R1
+
+decision_rules:
+  - id: phq2_positive_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: phq2_screen
+
+  - id: phq2_positive_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: phq2_screen
+
+  - id: phq2_positive_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: phq2_positive_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: followup_referral
diff --git a/list/taxonomy/phq2_positive/triggers.yaml b/list/taxonomy/phq2_positive/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4ec5601156151de8a8b4baf03bd1752bac0625f9
--- /dev/null
+++ b/list/taxonomy/phq2_positive/triggers.yaml
@@ -0,0 +1,76 @@
+domain: phq2_positive
+priority: 38
+
+lexical_signals:
+  high:
+    phrases:
+      - "feeling down all the time"
+      - "lost interest in everything"
+      - "hopeless about the future"
+      - "don't enjoy anything anymore"
+      - "don't care about anything"
+      - "what's the point of anything"
+      - "nothing matters anymore"
+      - "feeling worthless"
+      - "no motivation to do anything"
+      - "can't find pleasure in anything"
+      - "life feels pointless"
+      - "don't want to get out of bed"
+      - "crying all the time"
+      - "don't care anymore about anything"
+      - "everything feels empty"
+      - "no interest in things I used to enjoy"
+    regex:
+      - "(feeling|been|feel)\\s+(down|depressed|hopeless|worthless).{0,15}(all\\s+the\\s+time|every\\s+day|constantly|always)"
+      - "(lost|no|little|don't\\s+have)\\s+(interest|pleasure|motivation|enjoyment).{0,15}(in|for|to\\s+do).{0,10}(anything|things|life)"
+      - "(don't|doesn't|can't)\\s+(care|enjoy|find\\s+pleasure).{0,15}(anymore|any\\s+more|about\\s+anything)"
+      - "(what's\\s+the\\s+point|nothing\\s+matters|life\\s+feels?\\s+pointless|everything\\s+feels?\\s+empty)"
+  medium:
+    phrases:
+      - "feeling down"
+      - "little interest in things"
+      - "hopeless"
+      - "not enjoying things"
+      - "depressed lately"
+      - "don't care anymore"
+      - "feeling blue"
+      - "not myself lately"
+      - "lost motivation"
+      - "hard to get going"
+      - "things feel heavy"
+      - "low mood"
+      - "feeling empty"
+    regex:
+      - "(feeling|been|feel)\\s+(down|depressed|hopeless|blue|empty|low)"
+      - "(little|no|lost)\\s+(interest|motivation|enjoyment|pleasure)"
+      - "(not|don't)\\s+(enjoy|care).{0,10}(things|anymore|about)"
+  low:
+    partials:
+      - "depressed"
+      - "down"
+      - "hopeless"
+      - "no interest"
+      - "blue"
+      - "low mood"
+
+negation_handling:
+  patterns:
+    - "not depressed"
+    - "not feeling down"
+    - "feeling good"
+    - "enjoying life"
+    - "doing well"
+    - "feeling fine"
+    - "in a good mood"
+    - "feeling positive"
+    - "no depression"
+    - "not hopeless"
+    - "mood is good"
+    - "have interest in things"
+    - "enjoying my hobbies"
+    - "feeling like myself"
+    - "motivated"
+    - "feeling upbeat"
+    - "not blue"
+    - "mood has been great"
+  action: downgrade_confidence
diff --git a/list/taxonomy/poor_oral_intake/flows/clarify.yaml b/list/taxonomy/poor_oral_intake/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4a0b6bf180334c6b64c7303e1b1d37b58dd91911
--- /dev/null
+++ b/list/taxonomy/poor_oral_intake/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: poor_oral_intake
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: poor_oral_intake_clarify
+      goal: "Ask patient to describe their poor oral intake symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - poor_oral_intake_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/poor_oral_intake/flows/escalate_r1.yaml b/list/taxonomy/poor_oral_intake/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c80b8481a925f837ce3cac107bbfeb61adc8c152
--- /dev/null
+++ b/list/taxonomy/poor_oral_intake/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: poor_oral_intake
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/poor_oral_intake/flows/handoff.yaml b/list/taxonomy/poor_oral_intake/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f58bb522228589fb46f79479a1cf043749046e87
--- /dev/null
+++ b/list/taxonomy/poor_oral_intake/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: poor_oral_intake
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: poor_oral_intake_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: poor_oral_intake_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/poor_oral_intake/rules.yaml b/list/taxonomy/poor_oral_intake/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9a69d36c140c445af342cafcfe1325033e8df3ee
--- /dev/null
+++ b/list/taxonomy/poor_oral_intake/rules.yaml
@@ -0,0 +1,21 @@
+domain: poor_oral_intake
+target_risk_class: R1
+
+decision_rules:
+  - id: poor_oral_intake_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r1
+
+  - id: poor_oral_intake_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r1
+
+  - id: poor_oral_intake_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/poor_oral_intake/triggers.yaml b/list/taxonomy/poor_oral_intake/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a6c689dda81ce8bab4eea3288b3123055a5c7a97
--- /dev/null
+++ b/list/taxonomy/poor_oral_intake/triggers.yaml
@@ -0,0 +1,67 @@
+domain: poor_oral_intake
+priority: 42
+
+lexical_signals:
+  high:
+    phrases:
+      - "can't eat anything"
+      - "haven't eaten in days"
+      - "losing weight rapidly"
+      - "no appetite at all since discharge"
+      - "unable to eat or drink"
+      - "unintended weight loss"
+      - "can't keep anything down"
+      - "not drinking any fluids"
+      - "haven't had anything to eat or drink"
+      - "food makes me sick"
+      - "can't swallow anything"
+      - "lost a lot of weight"
+      - "haven't been able to eat since surgery"
+      - "completely lost my appetite"
+    regex:
+      - "(can'?t|unable\\s+to)\\s+(eat|drink|swallow|keep)"
+      - "haven'?t\\s+(eaten|had\\s+anything\\s+to\\s+eat)"
+      - "(losing|lost)\\s+(a\\s+lot\\s+of\\s+)?weight"
+      - "(no|lost|zero|completely\\s+lost)\\s+(my\\s+)?appetite"
+      - "not\\s+(eating|drinking)\\s+(anything|at\\s+all|much)"
+  medium:
+    phrases:
+      - "not eating much"
+      - "appetite is very poor"
+      - "losing weight since discharge"
+      - "barely eating anything"
+      - "don't want to eat"
+      - "only eating a little bit"
+      - "food doesn't taste good"
+      - "not hungry at all"
+      - "skipping meals"
+      - "forcing myself to eat"
+      - "just not interested in food"
+      - "eating less and less"
+  low:
+    partials:
+      - "poor appetite"
+      - "not eating"
+      - "weight loss"
+      - "no appetite"
+      - "can't eat"
+      - "not hungry"
+
+negation_handling:
+  patterns:
+    - "eating well"
+    - "appetite is fine"
+    - "no weight loss"
+    - "appetite is good"
+    - "eating normally"
+    - "eating fine"
+    - "appetite has returned"
+    - "appetite is back"
+    - "eating better"
+    - "keeping food down"
+    - "haven't had anything like that"
+    - "haven't had anything of the sort"
+    - "no, haven't had anything"
+    - "haven't had any of that"
+    - "no, nothing like that"
+  action: downgrade_confidence
diff --git a/list/taxonomy/post_discharge_engagement/flows/appointments_check.yaml b/list/taxonomy/post_discharge_engagement/flows/appointments_check.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9f512ec72c1e388edd1dc9b15c90ea09a4c54afc
--- /dev/null
+++ b/list/taxonomy/post_discharge_engagement/flows/appointments_check.yaml
@@ -0,0 +1,22 @@
+flow_id: appointments_check
+type: ask
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pde_appointments_check
+      goal: "Check if the patient has follow-up appointments scheduled and can get to them"
+      tone: warm_professional
+      must_include:
+        - "follow-up"
+        - "appointment"
+      must_ask:
+        - "do you have your follow-up appointments scheduled"
+      must_not:
+        - "must"
+        - "have to"
+      max_questions: 1
+    collects:
+      - appointment_barrier
diff --git a/list/taxonomy/post_discharge_engagement/flows/closing.yaml b/list/taxonomy/post_discharge_engagement/flows/closing.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..391c095ff2b079a9c509f6d1f84ae87bd8d96437
--- /dev/null
+++ b/list/taxonomy/post_discharge_engagement/flows/closing.yaml
@@ -0,0 +1,18 @@
+flow_id: closing
+type: respond
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: pde_closing
+      goal: "Thank the patient, summarize next steps, and close warmly"
+      tone: warm_professional
+      must_include:
+        - "thank you"
+        - "care team"
+      must_ask: []
+      must_not:
+        - "goodbye forever"
+      max_questions: 0
diff --git a/list/taxonomy/post_discharge_engagement/flows/discharge_context.yaml b/list/taxonomy/post_discharge_engagement/flows/discharge_context.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6bb17f66d6cbe27984b0d782d5da2a7e29ae84e3
--- /dev/null
+++ b/list/taxonomy/post_discharge_engagement/flows/discharge_context.yaml
@@ -0,0 +1,22 @@
+flow_id: discharge_context
+type: ask
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pde_discharge_context
+      goal: "Confirm discharge details and set context for the call"
+      tone: warm_professional
+      must_include:
+        - "discharged"
+        - "recovery"
+      must_ask:
+        - "how things have been going since you left the hospital"
+      must_not:
+        - "diagnos"
+        - "should be"
+      max_questions: 1
+    collects:
+      - discharge_context_ack
diff --git a/list/taxonomy/post_discharge_engagement/flows/emergency_plan_teachback.yaml b/list/taxonomy/post_discharge_engagement/flows/emergency_plan_teachback.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..58511dc4c39b5004b526d67e20c09200490ecb65
--- /dev/null
+++ b/list/taxonomy/post_discharge_engagement/flows/emergency_plan_teachback.yaml
@@ -0,0 +1,21 @@
+flow_id: emergency_plan_teachback
+type: ask
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pde_emergency_plan
+      goal: "Confirm the patient knows what to do and who to call in an emergency"
+      tone: warm_professional
+      must_include:
+        - "emergency"
+      must_ask:
+        - "if something feels wrong, what would you do"
+      must_not:
+        - "scare"
+        - "panic"
+      max_questions: 1
+    collects:
+      - emergency_plan_ack
diff --git a/list/taxonomy/post_discharge_engagement/flows/general_status.yaml b/list/taxonomy/post_discharge_engagement/flows/general_status.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..04cac9b29a929d95168e35e9ceca4b379a2fa20f
--- /dev/null
+++ b/list/taxonomy/post_discharge_engagement/flows/general_status.yaml
@@ -0,0 +1,21 @@
+flow_id: general_status
+type: ask
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pde_general_status
+      goal: "Ask the patient how they are feeling overall today"
+      tone: warm_empathetic
+      must_include:
+        - "feeling"
+      must_ask:
+        - "how are you feeling overall today"
+      must_not:
+        - "diagnos"
+        - "should be"
+      max_questions: 1
+    collects:
+      - health_status
diff --git a/list/taxonomy/post_discharge_engagement/flows/home_services_equipment.yaml b/list/taxonomy/post_discharge_engagement/flows/home_services_equipment.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4d0641aa22c0e2b3ab34998540c7ad4bfb86f979
--- /dev/null
+++ b/list/taxonomy/post_discharge_engagement/flows/home_services_equipment.yaml
@@ -0,0 +1,21 @@
+flow_id: home_services_equipment
+type: ask
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pde_home_services
+      goal: "Check if the patient needs any home health services or equipment"
+      tone: warm_professional
+      must_include:
+        - "home"
+      must_ask:
+        - "do you have everything you need at home, like equipment or home health services"
+      must_not:
+        - "must"
+        - "should"
+      max_questions: 1
+    collects:
+      - home_issue
diff --git a/list/taxonomy/post_discharge_engagement/flows/intro_permission.yaml b/list/taxonomy/post_discharge_engagement/flows/intro_permission.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..65f1b6af991bf5158e3381746c8592a3e4b3991a
--- /dev/null
+++ b/list/taxonomy/post_discharge_engagement/flows/intro_permission.yaml
@@ -0,0 +1,22 @@
+flow_id: intro_permission
+type: ask
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pde_intro_permission
+      goal: "Introduce yourself and ask permission to walk through a structured check-in"
+      tone: warm_professional
+      must_include:
+        - "post-discharge check-in"
+        - "recovery"
+      must_ask:
+        - "walk through a few topics together"
+      must_not:
+        - "diagnos"
+        - "medical advice"
+      max_questions: 1
+    collects:
+      - agenda_consent
diff --git a/list/taxonomy/post_discharge_engagement/flows/meds_reconciliation.yaml b/list/taxonomy/post_discharge_engagement/flows/meds_reconciliation.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c41061316e39254dd40a9b6d721575d8b1ed964d
--- /dev/null
+++ b/list/taxonomy/post_discharge_engagement/flows/meds_reconciliation.yaml
@@ -0,0 +1,21 @@
+flow_id: meds_reconciliation
+type: ask
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pde_meds_reconciliation
+      goal: "Check that the patient has their medications and can take them without barriers"
+      tone: warm_professional
+      must_include:
+        - "medication"
+      must_ask:
+        - "have you been able to get and take all your medications"
+      must_not:
+        - "must"
+        - "have to"
+      max_questions: 1
+    collects:
+      - meds_barrier
diff --git a/list/taxonomy/post_discharge_engagement/flows/pending_tests_check.yaml b/list/taxonomy/post_discharge_engagement/flows/pending_tests_check.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..720c34d2a22076ce8dad19c7ad3be330d7ff4fcc
--- /dev/null
+++ b/list/taxonomy/post_discharge_engagement/flows/pending_tests_check.yaml
@@ -0,0 +1,21 @@
+flow_id: pending_tests_check
+type: ask
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pde_pending_tests
+      goal: "Ask if the patient has any pending test results they are waiting for"
+      tone: warm_professional
+      must_include:
+        - "tests"
+        - "results"
+      must_ask:
+        - "are you waiting on any test results"
+      must_not:
+        - "diagnos"
+      max_questions: 1
+    collects:
+      - pending_tests_status
diff --git a/list/taxonomy/post_discharge_engagement/flows/problem_solving.yaml b/list/taxonomy/post_discharge_engagement/flows/problem_solving.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7846897cd6d426c3da342e23f6bf897e346e36eb
--- /dev/null
+++ b/list/taxonomy/post_discharge_engagement/flows/problem_solving.yaml
@@ -0,0 +1,18 @@
+flow_id: problem_solving
+type: respond
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: pde_problem_solving
+      goal: "Summarize any barriers identified and confirm tasks that will be created to help"
+      tone: warm_reassuring
+      must_include:
+        - "help"
+      must_ask: []
+      must_not:
+        - "your fault"
+        - "should have"
+      max_questions: 0
diff --git a/list/taxonomy/post_discharge_engagement/flows/symptom_review_collector.yaml b/list/taxonomy/post_discharge_engagement/flows/symptom_review_collector.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..24deb1fa0ef362aa988fdbcc3c310338b5614d79
--- /dev/null
+++ b/list/taxonomy/post_discharge_engagement/flows/symptom_review_collector.yaml
@@ -0,0 +1,21 @@
+flow_id: symptom_review_collector
+type: ask
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pde_symptom_review
+      goal: "Ask about any new or worsening symptoms since discharge"
+      tone: calm_professional
+      must_include:
+        - "symptoms"
+      must_ask:
+        - "any new or worsening symptoms since you came home"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 1
+    collects:
+      - symptom_free_text
diff --git a/list/taxonomy/post_discharge_engagement/flows/teachback_diagnosis.yaml b/list/taxonomy/post_discharge_engagement/flows/teachback_diagnosis.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c0a95a9391e75595f3f4ebb94632705d11a71613
--- /dev/null
+++ b/list/taxonomy/post_discharge_engagement/flows/teachback_diagnosis.yaml
@@ -0,0 +1,22 @@
+flow_id: teachback_diagnosis
+type: ask
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pde_teachback_diagnosis
+      goal: "Teach-back: ask the patient to describe their main health problem in their own words"
+      tone: warm_curious
+      must_include:
+        - "own words"
+      must_ask:
+        - "what is the main health problem you were treated for"
+      must_not:
+        - "wrong"
+        - "incorrect"
+        - "test"
+      max_questions: 1
+    collects:
+      - teachback_main_problem
diff --git a/list/taxonomy/post_discharge_engagement/flows/teachback_warning_signs.yaml b/list/taxonomy/post_discharge_engagement/flows/teachback_warning_signs.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7547425687648e44ec5f354101f24615b96ec30f
--- /dev/null
+++ b/list/taxonomy/post_discharge_engagement/flows/teachback_warning_signs.yaml
@@ -0,0 +1,22 @@
+flow_id: teachback_warning_signs
+type: ask
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pde_teachback_warning_signs
+      goal: "Teach-back: ask the patient to name warning signs they should watch for"
+      tone: warm_curious
+      must_include:
+        - "warning signs"
+      must_ask:
+        - "what warning signs were you told to watch for"
+      must_not:
+        - "wrong"
+        - "incorrect"
+        - "test"
+      max_questions: 1
+    collects:
+      - teachback_warning_signs
diff --git a/list/taxonomy/post_discharge_engagement/flows/wrap_up.yaml b/list/taxonomy/post_discharge_engagement/flows/wrap_up.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..75a168d5a8d6c1ee8da1c5404b8b6e8e048df3dc
--- /dev/null
+++ b/list/taxonomy/post_discharge_engagement/flows/wrap_up.yaml
@@ -0,0 +1,16 @@
+flow_id: wrap_up
+type: respond
+domain: post_discharge_engagement
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: pde_wrap_up
+      goal: "Final sign-off after agenda is complete"
+      tone: warm_professional
+      must_include:
+        - "take care"
+      must_ask: []
+      must_not: []
+      max_questions: 0
diff --git a/list/taxonomy/post_discharge_engagement/rules.yaml b/list/taxonomy/post_discharge_engagement/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e703b18d789826fa7d2c25d6cf189f9e4777d617
--- /dev/null
+++ b/list/taxonomy/post_discharge_engagement/rules.yaml
@@ -0,0 +1,86 @@
+domain: post_discharge_engagement
+
+decision_rules:
+  - id: pde_intro_permission
+    if:
+      agenda_step: intro_permission
+    then:
+      flow: intro_permission
+
+  - id: pde_discharge_context
+    if:
+      agenda_step: discharge_context
+    then:
+      flow: discharge_context
+
+  - id: pde_teachback_diagnosis
+    if:
+      agenda_step: teachback_diagnosis
+    then:
+      flow: teachback_diagnosis
+
+  - id: pde_teachback_warning_signs
+    if:
+      agenda_step: teachback_warning_signs
+    then:
+      flow: teachback_warning_signs
+
+  - id: pde_general_status
+    if:
+      agenda_step: general_status
+    then:
+      flow: general_status
+
+  - id: pde_symptom_review
+    if:
+      agenda_step: symptom_review
+    then:
+      flow: symptom_review_collector
+
+  - id: pde_meds_reconciliation
+    if:
+      agenda_step: meds_reconciliation
+    then:
+      flow: meds_reconciliation
+
+  - id: pde_appointments_check
+    if:
+      agenda_step: appointments_check
+    then:
+      flow: appointments_check
+
+  - id: pde_pending_tests
+    if:
+      agenda_step: pending_tests
+    then:
+      flow: pending_tests_check
+
+  - id: pde_home_services
+    if:
+      agenda_step: home_services
+    then:
+      flow: home_services_equipment
+
+  - id: pde_problem_solving
+    if:
+      agenda_step: problem_solving
+    then:
+      flow: problem_solving
+
+  - id: pde_emergency_plan
+    if:
+      agenda_step: emergency_plan
+    then:
+      flow: emergency_plan_teachback
+
+  - id: pde_closing
+    if:
+      agenda_step: closing
+    then:
+      flow: closing
+
+  - id: pde_wrap_up
+    if:
+      agenda_step: wrap_up
+    then:
+      flow: wrap_up
diff --git a/list/taxonomy/post_discharge_engagement/triggers.yaml b/list/taxonomy/post_discharge_engagement/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f231ce7f67d5db61d4182f25edcdad0e60361a16
--- /dev/null
+++ b/list/taxonomy/post_discharge_engagement/triggers.yaml
@@ -0,0 +1,8 @@
+domain: post_discharge_engagement
+priority: 0
+
+# Empty signals — this domain is agenda-driven, not nomination-driven.
+# It becomes the default control path after consent completes with no
+# safety signals.  The engine activates it by setting agenda_step, not
+# through lexical nomination.
+lexical_signals: {}
diff --git a/list/taxonomy/post_discharge_fever/flows/clarify.yaml b/list/taxonomy/post_discharge_fever/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..bf28c28e664f19be1fc55e4b627f8bf218da71f6
--- /dev/null
+++ b/list/taxonomy/post_discharge_fever/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: post_discharge_fever
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: post_discharge_fever_clarify
+      goal: "Ask patient to describe their post discharge fever symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - post_discharge_fever_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/post_discharge_fever/flows/escalate_r2.yaml b/list/taxonomy/post_discharge_fever/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f8b95af461ad0cafb5da907af858a82e95be5a76
--- /dev/null
+++ b/list/taxonomy/post_discharge_fever/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: post_discharge_fever
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/post_discharge_fever/flows/escalate_r3.yaml b/list/taxonomy/post_discharge_fever/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e6c158c7f9ad8308863f9b441bb107259cb84977
--- /dev/null
+++ b/list/taxonomy/post_discharge_fever/flows/escalate_r3.yaml
@@ -0,0 +1,26 @@
+flow_id: escalate_r3
+type: escalation
+domain: post_discharge_fever
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: fever_r3_escalation_notice
+    goal: Instruct patient to go to the emergency department immediately for very
+      high fever with concerning symptoms
+    tone: calm_urgent
+    must_include:
+    - call 911
+    - emergency
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - wait and see
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+exit:
+  on_complete: end
diff --git a/list/taxonomy/post_discharge_fever/flows/handoff.yaml b/list/taxonomy/post_discharge_fever/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..78cdeb8aa2e9a3147915b4f2e3fe793f4fe7986f
--- /dev/null
+++ b/list/taxonomy/post_discharge_fever/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: post_discharge_fever
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: post_discharge_fever_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: post_discharge_fever_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/post_discharge_fever/flows/safety_screen.yaml b/list/taxonomy/post_discharge_fever/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..82e4f3434445b002154bfcae6981e6b209149d2f
--- /dev/null
+++ b/list/taxonomy/post_discharge_fever/flows/safety_screen.yaml
@@ -0,0 +1,54 @@
+flow_id: safety_screen
+type: screening
+domain: post_discharge_fever
+
+required_slots:
+  - temperature_reading
+  - fever_onset
+  - other_symptoms
+  - recent_procedure
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "temperature reading"
+        - "fever onset"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - temperature_reading
+      - fever_onset
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "other symptoms"
+        - "recent procedure"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - other_symptoms
+      - recent_procedure
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/list/taxonomy/post_discharge_fever/rules.yaml b/list/taxonomy/post_discharge_fever/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a60c5265f9bb0ea455abbdcb896b33e583f378a8
--- /dev/null
+++ b/list/taxonomy/post_discharge_fever/rules.yaml
@@ -0,0 +1,33 @@
+domain: post_discharge_fever
+target_risk_class: R2
+
+decision_rules:
+  - id: post_discharge_fever_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: post_discharge_fever_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: post_discharge_fever_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: post_discharge_fever_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: post_discharge_fever_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/post_discharge_fever/triggers.yaml b/list/taxonomy/post_discharge_fever/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4c57f82055e1e1bd3549c73c4c8d5cfad5ca5a70
--- /dev/null
+++ b/list/taxonomy/post_discharge_fever/triggers.yaml
@@ -0,0 +1,182 @@
+domain: post_discharge_fever
+priority: 68
+
+lexical_signals:
+  high:
+    phrases:
+      - "fever of 101 since discharge"
+      - "temperature is 102"
+      - "high fever after surgery"
+      - "spiked a fever post-discharge"
+      - "fever over 38.5"
+      - "post-op fever"
+      - "got home from the hospital and started feeling warm"
+      - "discharged and now I feel hot"
+      - "fever since coming home from hospital"
+      - "acting feverish since surgery"
+      - "temperature hit 103"
+      - "thermometer says 101.5"
+      - "fever and chills after my surgery"
+      - "burning up since I got home from the hospital"
+      - "running 102 since they sent me home"
+      - "came home from surgery and now have a fever"
+      - "spiked to 104 after getting discharged"
+      - "temp keeps climbing since my procedure"
+      - "incision is red and I have a fever"
+      - "fever and the wound looks infected"
+    regex:
+      - "(fever|temp|temperature)\\s+(of\\s+|was\\s+|is\\s+|said\\s+)?1(0[1-9]|[1-9]\\d)"
+      - "fever.*post.?(op|discharge|surgery)"
+      - "(discharg|hospital|surgery|procedure).*(fever|hot|warm|feverish|shaky)"
+      - "(fever|hot|warm|feverish).*(discharg|hospital|surgery|procedure|came home|got home)"
+      - "(temp|temperature).*(100\\.[4-9]|10[1-9]|1[1-9]\\d)"
+      - "(thermometer|temp).{0,10}(say|read|show|said|reads|shows).{0,5}(10[1-9]|1[1-9]\\d)"
+      - "(burn|burning)\\s+up.{0,15}(since|after).{0,10}(home|hospital|discharg|surgery)"
+      - "(running|spiked?|hit|reach).{0,5}(a\\s+)?(10[1-9]|1[1-9]\\d).{0,15}(since|after).{0,15}(home|hospital|discharg|surgery|sent)"
+      - "(came|got|been)\\s+home.{0,10}(from\\s+)?(surgery|hospital|procedure).{0,15}(fever|temp|hot)"
+      - "(fever|temp).{0,10}(keep|keeps|kept).{0,10}(climb|go|ris|creep)"
+      - "(incision|wound|site|stitches).{0,15}(red|warm|hot|infect).{0,15}fever"
+      - "fever.{0,15}(incision|wound|site|stitches).{0,15}(red|warm|hot|infect)"
+  medium:
+    phrases:
+      - "fever since coming home"
+      - "temperature elevated since discharge"
+      - "running a fever"
+      - "feel feverish and was just discharged"
+      - "fever after procedure"
+      - "temperature keeps going up"
+      - "sweaty and a little shaky"
+      - "feel hot and shaky"
+      - "started feeling warm"
+      - "got home from the hospital"
+      - "incision area feels sore"
+      - "shivery episode"
+      - "flipping between sweaty and cold"
+      - "forehead feels warm"
+      - "acting off since I got home"
+      - "something went wrong after the hospital"
+      - "woke up soaked in sweat after my surgery"
+      - "teeth chattering and I just had surgery"
+      - "my skin feels hot to the touch since I got home"
+      - "body aches and chills since the procedure"
+      - "I just do not feel right since they let me go"
+      - "came home yesterday and now I feel terrible"
+      - "whole body is shaking since the operation"
+      - "been running hot since they took my catheter out"
+      - "my face is flushed and I had surgery two days ago"
+      - "night sweats since coming home from hospital"
+      - "alternating between hot and cold since my procedure"
+      - "kids say my forehead is really warm"
+      - "feel like I am coming down with something after my operation"
+    regex:
+      - "(sweaty|shaky|shiver|chill).*(discharg|hospital|surgery|home)"
+      - "(discharg|hospital|surgery|home).*(sweaty|shaky|shiver|chill|warm|hot)"
+      - "(feel|feeling)\\s+(kinda?|kind\\s+of|a\\s+bit|sort\\s+of\\s+)?(warm|hot|feverish)"
+      - "(got|came|been)\\s+home\\s+(from\\s+)?(the\\s+)?hospital"
+      - "(just|recently)\\s+(discharged|released|got\\s+out|came\\s+home)"
+      - "after\\s+(my|the|his|her)\\s+\\w+\\s+surgery"
+      - "(shiver|chill|rigor|sweating).*(and|then).*(cold|hot|warm)"
+      - "after\\s+(my|the|his|her)\\s+(gallbladder|knee|hip|heart|back|shoulder|hernia)\\s+surgery"
+      - "after\\s+(a|the)\\s+(knee|hip)\\s+arthroscop"
+      - "discharged\\s+yesterday"
+      - "body\\s+is.*doing\\s+this"
+      - "just\\s+got.*home\\s+and\\s+now"
+      - "feel\\s+(kind\\s+of\\s+)?warm"
+      - "feel\\s+(kinda?)\\s+warm"
+      - "feel\\s+(really\\s+)?hot\\s+and\\s+shaky"
+      - "feels?\\s+a\\s+bit\\s+warm"
+      - "not\\s+acting\\s+right"
+      - "(woke|wake).{0,5}up.{0,10}(soaked|drenched|dripping).{0,10}(in\\s+)?sweat"
+      - "(teeth|body).{0,5}(chatter|shak).{0,10}(since|after).{0,10}(surgery|procedure|operation|hospital)"
+      - "skin.{0,10}(hot|warm|burning).{0,10}(to\\s+the\\s+)?touch"
+      - "(body\\s+ache|aching|achy).{0,15}(chill|shiver|shak).{0,15}(since|after|procedure|surgery)"
+      - "(don[']?t|do\\s+not)\\s+feel\\s+right\\s+since"
+      - "(came|got)\\s+home\\s+(yesterday|today|last\\s+night).{0,15}(feel|now)"
+      - "(whole\\s+)?body.{0,5}(is\\s+)?(shak|trembl)"
+      - "(running|been)\\s+hot\\s+since"
+      - "(face|cheeks?|skin).{0,10}(flush|red|hot|warm)"
+      - "night\\s+sweat.{0,15}(since|after|home|hospital|surgery)"
+      - "(hot\\s+and\\s+cold|cold\\s+and\\s+hot|alternating).{0,15}(since|after|procedure|surgery)"
+      - "(wife|husband|kid|son|daughter|spouse|partner).{0,10}(say|said|notice).{0,10}(warm|hot|fever|flush)"
+      - "(coming\\s+down|getting\\s+sick|caught\\s+something).{0,15}(after|since|operation|surgery|procedure)"
+  low:
+    partials:
+      - "fever"
+      - "temperature elevated"
+      - "feverish"
+      - "sweaty and shaky"
+      - "feel warm"
+      - "feel hot"
+      - "chills"
+      - "shivery"
+      - "discharged"
+      - "after surgery"
+      - "post-op"
+      - "since hospital"
+      - "night sweats"
+      - "body aches"
+      - "burning up"
+      - "flushed"
+      - "rigors"
+      - "cold sweats"
+
+negation_handling:
+  patterns:
+    - "no fever"
+    - "temperature is normal"
+    - "fever broke"
+    - "not feverish"
+    - "chills resolved"
+    - "temp is 98.6"
+    - "temperature came back down"
+    - "fever went away"
+    - "feeling better now"
+    - "no longer feverish"
+    - "temperature has been normal since discharge"
+    - "checked my temp and it is normal"
+    - "was warm but it passed"
+    - "chills went away on their own"
+    - "fever was from the anesthesia and it resolved"
+    - "only had a low grade temp briefly"
+    - "not running a fever anymore"
+    - "temp came down after tylenol"
+    - "sweating but temp is normal"
+    - "no fever no chills"
+    # --- post-procedure incontinence context (R1 scenarios) ---
+    - "incontinence"
+    - "urine leakage"
+    - "leaking urine"
+    - "bladder control"
+    - "bladder surgery"
+    - "prostate surgery"
+    - "prostate procedure"
+    - "pelvic floor"
+    - "wearing pads"
+    - "catheter removal"
+    - "after the catheter"
+    - "leaking since surgery"
+    - "didn't take my temperature"
+    - "haven't checked my temperature"
+    # --- wound care / healing context ---
+    - "healing"
+    - "wound care"
+    - "dressing change"
+    - "bandage change"
+    - "wound check"
+    - "stitches"
+    - "wound looks"
+    - "incision looks"
+    # --- scheduling context ---
+    - "scheduling"
+    - "schedule an appointment"
+    - "make an appointment"
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_has_condition: ["Z96.*"]
+      reason: "Prosthetic joint infection risk with fever"
+    - when:
+        patient_has_condition: ["D70.*"]
+      reason: "Neutropenia with fever is emergent"
diff --git a/list/taxonomy/post_procedure_incontinence/flows/clarify.yaml b/list/taxonomy/post_procedure_incontinence/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9d022b641727d7ad4ae57b297e7284634903dab2
--- /dev/null
+++ b/list/taxonomy/post_procedure_incontinence/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: post_procedure_incontinence
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: post_procedure_incontinence_clarify
+      goal: "Ask patient to describe their post procedure incontinence symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - post_procedure_incontinence_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/post_procedure_incontinence/flows/escalate_r1.yaml b/list/taxonomy/post_procedure_incontinence/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c628d59cc92fbe322d902f3748dd65ca91aa8e33
--- /dev/null
+++ b/list/taxonomy/post_procedure_incontinence/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: post_procedure_incontinence
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/post_procedure_incontinence/flows/handoff.yaml b/list/taxonomy/post_procedure_incontinence/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..dff1a9029c79df8bb3321f7c167e62c7a104feff
--- /dev/null
+++ b/list/taxonomy/post_procedure_incontinence/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: post_procedure_incontinence
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: post_procedure_incontinence_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: post_procedure_incontinence_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/post_procedure_incontinence/rules.yaml b/list/taxonomy/post_procedure_incontinence/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..904939b536fc5dafe25340c7920ee29fa0e3e523
--- /dev/null
+++ b/list/taxonomy/post_procedure_incontinence/rules.yaml
@@ -0,0 +1,21 @@
+domain: post_procedure_incontinence
+target_risk_class: R1
+
+decision_rules:
+  - id: post_procedure_incontinence_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r1
+
+  - id: post_procedure_incontinence_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r1
+
+  - id: post_procedure_incontinence_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/post_procedure_incontinence/triggers.yaml b/list/taxonomy/post_procedure_incontinence/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3aebd4914ce0bdfa542d5ed1694aeb007caf51bf
--- /dev/null
+++ b/list/taxonomy/post_procedure_incontinence/triggers.yaml
@@ -0,0 +1,51 @@
+domain: post_procedure_incontinence
+priority: 37
+
+lexical_signals:
+  high:
+    phrases:
+      - "can't hold my urine since surgery"
+      - "new incontinence after procedure"
+      - "leaking urine since operation"
+      - "fecal incontinence after surgery"
+      - "lost bladder control post-op"
+      - "new bowel incontinence since procedure"
+      - "wetting myself since the surgery"
+      - "can't control my bladder anymore"
+      - "urine just comes out on its own"
+      - "having accidents since the operation"
+      - "peeing on myself"
+      - "can't make it to the bathroom in time"
+      - "soiling myself since discharge"
+    regex:
+      - "(incontinence|leaking|wetting|accidents).*(surgery|procedure|operation|post.?op|since)"
+      - "(can'?t|lost|losing)\\s+(hold|control).*\\s*(bladder|urine|bowel)"
+      - "(bladder|bowel)\\s+(control|problem|issue).*\\s*(since|after|post)"
+  medium:
+    phrases:
+      - "trouble controlling bladder since surgery"
+      - "some urinary leaking"
+      - "incontinence since procedure"
+      - "bladder issues after surgery"
+      - "bowel control problems post-op"
+      - "leaking a little bit"
+      - "dribbling urine"
+      - "wearing pads for leaking"
+      - "bladder doesn't feel right"
+      - "having some accidents"
+      - "trouble holding it"
+  low:
+    partials:
+      - "incontinence"
+      - "leaking urine"
+      - "bladder control"
+      - "wetting"
+      - "accidents"
+      - "can't hold it"
+
+negation_handling:
+  patterns:
+    - "no incontinence"
+    - "bladder control fine"
+    - "no leaking"
+  action: downgrade_confidence
diff --git a/list/taxonomy/pre_op_anesthesia_concern/flows/clarify_anesthesia.yaml b/list/taxonomy/pre_op_anesthesia_concern/flows/clarify_anesthesia.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..267a156bb17b3fc6dce082e5fcf99411665e101f
--- /dev/null
+++ b/list/taxonomy/pre_op_anesthesia_concern/flows/clarify_anesthesia.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify_anesthesia
+type: clarification
+domain: pre_op_anesthesia_concern
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: anesthesia_clarify
+      goal: "Ask patient to describe their anesthesia concern in more detail"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - anesthesia_concern_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/pre_op_anesthesia_concern/flows/escalate_r2.yaml b/list/taxonomy/pre_op_anesthesia_concern/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..37c3f726165470149faa2fde63c373ef49328305
--- /dev/null
+++ b/list/taxonomy/pre_op_anesthesia_concern/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: pre_op_anesthesia_concern
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: anesthesia_r2_escalation_notice
+      goal: "Inform patient that the anesthesia team will follow up about their concern before surgery"
+      tone: calm_reassuring
+      must_include:
+        - "anesthesia team"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: anesthesia_team
+    urgency: same_day
+    response_spec:
+      id: anesthesia_r2_handoff
+      goal: "Schedule same-day anesthesia team notification with patient history context"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/pre_op_anesthesia_concern/flows/escalate_r3.yaml b/list/taxonomy/pre_op_anesthesia_concern/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..23e98953bccae61d9e0ca0d55f45180b0f928418
--- /dev/null
+++ b/list/taxonomy/pre_op_anesthesia_concern/flows/escalate_r3.yaml
@@ -0,0 +1,40 @@
+flow_id: escalate_r3
+type: escalation
+domain: pre_op_anesthesia_concern
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: anesthesia_r3_escalation_notice
+    goal: Inform patient that their surgery team and anesthesiologist must be notified
+      urgently about the malignant hyperthermia risk before surgery proceeds
+    tone: calm_urgent
+    must_include:
+    - anesthesia team
+    - important
+    - before surgery
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably nothing
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: anesthesia_team
+  urgency: immediate
+  response_spec:
+    id: anesthesia_r3_handoff
+    goal: Immediate notification to anesthesia team about malignant hyperthermia family
+      history
+    tone: professional
+    must_include:
+    - malignant hyperthermia
+    - family history
+    must_ask: []
+    must_not: []
+exit:
+  on_complete: end
diff --git a/list/taxonomy/pre_op_anesthesia_concern/flows/reassure_low_risk.yaml b/list/taxonomy/pre_op_anesthesia_concern/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1800a4983fba2798ebdf4f680eae3bc02fad29a7
--- /dev/null
+++ b/list/taxonomy/pre_op_anesthesia_concern/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: reassurance
+domain: pre_op_anesthesia_concern
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: anesthesia_reassure
+      goal: "Reassure the patient and provide guidance about discussing anesthesia concerns with their surgical team"
+      tone: warm_reassuring
+      must_include:
+        - "anesthesia team"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/pre_op_anesthesia_concern/flows/screen_anesthesia_history.yaml b/list/taxonomy/pre_op_anesthesia_concern/flows/screen_anesthesia_history.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f6bfe98d4af131c088ac86218d18305790aca07f
--- /dev/null
+++ b/list/taxonomy/pre_op_anesthesia_concern/flows/screen_anesthesia_history.yaml
@@ -0,0 +1,82 @@
+flow_id: screen_anesthesia_history
+type: screening
+domain: pre_op_anesthesia_concern
+
+required_slots:
+  - prior_anesthesia_reaction
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: anesthesia_screen_step1
+      goal: "Determine whether the patient has had previous anesthesia experiences and any adverse reactions"
+      tone: warm_professional
+      must_include:
+        - "anesthesia"
+      must_ask:
+        - "Have you had anesthesia before, and if so, did you have any problems or reactions?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+        - "overreacting"
+      max_questions: 1
+    collects:
+      - prior_anesthesia_reaction
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: anesthesia_screen_step2
+      goal: "Assess family history of anesthesia complications including malignant hyperthermia"
+      tone: warm_professional
+      must_include:
+        - "family"
+      must_ask:
+        - "Has anyone in your family ever had a serious problem with anesthesia?"
+      must_not:
+        - "don't worry"
+        - "rare"
+      max_questions: 1
+    collects:
+      - family_anesthesia_history
+
+  - step: 3
+    type: ask
+    response_spec:
+      id: anesthesia_screen_step3
+      goal: "Screen for prior difficult intubation or airway concerns"
+      tone: warm_professional
+      must_include:
+        - "breathing tube"
+      must_ask:
+        - "Have you ever been told you had a difficult airway or problems with a breathing tube during surgery?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 1
+    collects:
+      - airway_concern
+
+  - step: 4
+    type: ask
+    response_spec:
+      id: anesthesia_screen_step4
+      goal: "Screen for post-operative nausea and vomiting history"
+      tone: warm_professional
+      must_include:
+        - "nausea"
+      must_ask:
+        - "Have you experienced significant nausea or vomiting after previous surgeries?"
+      must_not:
+        - "don't worry"
+        - "normal"
+      max_questions: 1
+    collects:
+      - ponv_history
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_low_risk: reassure_low_risk
+  on_unclear: handoff
diff --git a/list/taxonomy/pre_op_anesthesia_concern/rules.yaml b/list/taxonomy/pre_op_anesthesia_concern/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..dbd245c23bedae456869724091ead1de1914e6fe
--- /dev/null
+++ b/list/taxonomy/pre_op_anesthesia_concern/rules.yaml
@@ -0,0 +1,33 @@
+domain: pre_op_anesthesia_concern
+target_risk_class: R1
+
+decision_rules:
+  - id: pre_op_anesthesia_concern_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: screen_anesthesia_history
+
+  - id: pre_op_anesthesia_concern_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: screen_anesthesia_history
+
+  - id: pre_op_anesthesia_concern_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify_anesthesia
+
+  - id: pre_op_anesthesia_concern_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
+
+  - id: pre_op_anesthesia_concern_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
diff --git a/list/taxonomy/pre_op_anesthesia_concern/triggers.yaml b/list/taxonomy/pre_op_anesthesia_concern/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6d5d3feb233283691709545c90194461f695cb9f
--- /dev/null
+++ b/list/taxonomy/pre_op_anesthesia_concern/triggers.yaml
@@ -0,0 +1,75 @@
+domain: pre_op_anesthesia_concern
+priority: 52
+
+lexical_signals:
+  high:
+    phrases:
+      - "bad reaction to anesthesia before"
+      - "terrible experience with anesthesia"
+      - "adverse reaction to sedation"
+      - "malignant hyperthermia"
+      - "family member died from anesthesia"
+      - "relative had a problem with anesthesia"
+      - "almost died during surgery from anesthesia"
+      - "had a severe reaction going under"
+      - "family history of anesthesia complications"
+      - "allergic reaction to anesthesia"
+      - "woke up during surgery"
+      - "couldn't be intubated last time"
+      - "difficult airway"
+      - "bad time with anesthesia before"
+      - "anesthesia made me stop breathing"
+    regex:
+      - "(?:bad|adverse|terrible).{0,15}(?:reaction|experience|time).{0,15}(?:anesthesia|sedation|going under)"
+      - "malignant hyperthermia"
+      - "(?:family|relative).{0,15}(?:died|problem|reaction|complication).{0,15}(?:anesthesia|surgery)"
+      - "(?:woke up|awareness).{0,15}(?:during|middle of).{0,10}(?:surgery|procedure|operation)"
+      - "(?:difficult|couldn't|unable).{0,15}(?:intubat|airway)"
+  medium:
+    phrases:
+      - "worried about anesthesia"
+      - "scared of going under"
+      - "afraid of sedation"
+      - "nervous about anesthesia"
+      - "got really sick after anesthesia last time"
+      - "nausea after surgery last time"
+      - "vomited after anesthesia"
+      - "sick from anesthesia before"
+      - "threw up after my last surgery"
+      - "worried about waking up during surgery"
+      - "scared I won't wake up"
+      - "anxiety about being put under"
+    regex:
+      - "(?:worried|scared|afraid|nervous).{0,15}(?:anesthesia|going under|sedation)"
+      - "(?:nausea|vomit|sick).{0,15}(?:after|from).{0,15}(?:anesthesia|surgery|last time)"
+      - "(?:threw up|throwing up|got sick).{0,15}(?:after|from).{0,15}(?:anesthesia|surgery|last)"
+  low:
+    phrases:
+      - "anesthesia question"
+      - "anesthesia concern"
+      - "question about going under"
+      - "general anesthesia"
+      - "local anesthesia"
+      - "worried about anesthesia"
+    partials:
+      - "anesthesia"
+      - "sedation question"
+
+negation_handling:
+  patterns:
+    - "no problems with anesthesia before"
+    - "anesthesia went fine last time"
+    - "no bad reactions"
+    - "tolerated anesthesia well"
+    - "no family history of anesthesia problems"
+    - "no issues going under"
+    - "anesthesia was fine"
+    - "no concerns about anesthesia"
+    - "did well with anesthesia before"
+    - "no nausea after anesthesia"
+    - "no vomiting last time"
+    - "no anesthesia complications"
+    - "handled anesthesia well"
+    - "no allergies to anesthesia"
+    - "comfortable with anesthesia"
+  action: downgrade_confidence
diff --git a/list/taxonomy/pre_op_cardiac_clearance/flows/clarify_cardiac_preop.yaml b/list/taxonomy/pre_op_cardiac_clearance/flows/clarify_cardiac_preop.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f9a62191728b6bf76f0bc988af04fefafad23065
--- /dev/null
+++ b/list/taxonomy/pre_op_cardiac_clearance/flows/clarify_cardiac_preop.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify_cardiac_preop
+type: clarification
+domain: pre_op_cardiac_clearance
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: cardiac_preop_clarify
+      goal: "Ask patient to describe their cardiac concern in more detail"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - cardiac_preop_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/pre_op_cardiac_clearance/flows/escalate_cardiac_preop.yaml b/list/taxonomy/pre_op_cardiac_clearance/flows/escalate_cardiac_preop.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0326aa92698ccfdeae7be70ecef0cfea05233bc7
--- /dev/null
+++ b/list/taxonomy/pre_op_cardiac_clearance/flows/escalate_cardiac_preop.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_cardiac_preop
+type: escalation
+domain: pre_op_cardiac_clearance
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: cardiac_preop_escalation_notice
+      goal: "Inform patient that the surgeon and cardiologist need to be notified about new cardiac symptoms before proceeding with surgery"
+      tone: calm_reassuring
+      must_include:
+        - "surgeon"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: surgical_nurse
+    urgency: same_day
+    response_spec:
+      id: cardiac_preop_escalation_handoff
+      goal: "Schedule same-day surgeon and cardiologist notification about new cardiac symptoms"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/pre_op_cardiac_clearance/flows/escalate_r2.yaml b/list/taxonomy/pre_op_cardiac_clearance/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..cf63707e8420f9f4159325576bfdbc77e8ed363f
--- /dev/null
+++ b/list/taxonomy/pre_op_cardiac_clearance/flows/escalate_r2.yaml
@@ -0,0 +1,24 @@
+flow_id: escalate_r2
+type: escalation
+domain: pre_op_cardiac_clearance
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient about urgency of new cardiac symptoms before surgery and transfer to surgical team for same-day evaluation"
+      tone: calm_direct
+      must_include:
+        - "nurse"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably nothing"
+        - "wait and see"
+      max_questions: 0
+
+exit:
+  on_complete: handoff
diff --git a/list/taxonomy/pre_op_cardiac_clearance/flows/reassure_low_risk.yaml b/list/taxonomy/pre_op_cardiac_clearance/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..73d3b3614cc4665f0e00cd574ee79bb4fa8205d6
--- /dev/null
+++ b/list/taxonomy/pre_op_cardiac_clearance/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: reassurance
+domain: pre_op_cardiac_clearance
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: cardiac_preop_reassure
+      goal: "Reassure the patient that their cardiac clearance remains valid and provide guidance"
+      tone: warm_reassuring
+      must_include:
+        - "clearance"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/pre_op_cardiac_clearance/flows/screen_cardiac_preop.yaml b/list/taxonomy/pre_op_cardiac_clearance/flows/screen_cardiac_preop.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c14501380b21aceeacc8605cc35c4899d1f6b99e
--- /dev/null
+++ b/list/taxonomy/pre_op_cardiac_clearance/flows/screen_cardiac_preop.yaml
@@ -0,0 +1,48 @@
+flow_id: screen_cardiac_preop
+type: screening
+domain: pre_op_cardiac_clearance
+
+required_slots:
+  - new_cardiac_symptom
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: cardiac_preop_screen_step1
+      goal: "Determine whether the patient has developed new cardiac symptoms since their clearance"
+      tone: calm_urgent
+      must_include:
+        - "heart"
+      must_ask:
+        - "Have you had any new chest pain, shortness of breath, palpitations, or dizziness since your cardiac clearance?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - new_cardiac_symptom
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: cardiac_preop_screen_step2
+      goal: "Assess changes in exercise tolerance since clearance"
+      tone: calm_urgent
+      must_include:
+        - "activity"
+      must_ask:
+        - "Have you noticed any changes in what you can do physically, like walking or climbing stairs?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 1
+    collects:
+      - activity_tolerance_change
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_cardiac_preop
+  on_r3: escalate_cardiac_preop
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_cardiac_preop
diff --git a/list/taxonomy/pre_op_cardiac_clearance/rules.yaml b/list/taxonomy/pre_op_cardiac_clearance/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d7dcf3f98852882acaf3cf9567effb7eef514563
--- /dev/null
+++ b/list/taxonomy/pre_op_cardiac_clearance/rules.yaml
@@ -0,0 +1,33 @@
+domain: pre_op_cardiac_clearance
+target_risk_class: R2
+
+decision_rules:
+  - id: pre_op_cardiac_clearance_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: screen_cardiac_preop
+
+  - id: pre_op_cardiac_clearance_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: screen_cardiac_preop
+
+  - id: pre_op_cardiac_clearance_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify_cardiac_preop
+
+  - id: pre_op_cardiac_clearance_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_cardiac_preop
+
+  - id: pre_op_cardiac_clearance_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_cardiac_preop
diff --git a/list/taxonomy/pre_op_cardiac_clearance/triggers.yaml b/list/taxonomy/pre_op_cardiac_clearance/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3942f3b4c54d0879c8ef68678241949176ddfaa1
--- /dev/null
+++ b/list/taxonomy/pre_op_cardiac_clearance/triggers.yaml
@@ -0,0 +1,70 @@
+domain: pre_op_cardiac_clearance
+priority: 68
+
+lexical_signals:
+  high:
+    phrases:
+      - "chest pain since my cardiac clearance"
+      - "new heart symptoms before surgery"
+      - "palpitations since I saw the cardiologist"
+      - "racing heart since clearance"
+      - "chest pain started after I was cleared"
+      - "heart feels different since my clearance"
+      - "new chest tightness since cardiac clearance"
+      - "having palpitations since I was cleared for surgery"
+      - "started getting dizzy after my heart clearance"
+      - "chest pressure since seeing the cardiologist"
+      - "new cardiac symptoms before my procedure"
+      - "heart racing since I got cleared"
+      - "shortness of breath since cardiac clearance"
+      - "chest pain and my surgery is coming up"
+      - "heart problem since clearance"
+    regex:
+      - "(?:chest pain|palpitation|racing heart).{0,20}(?:since|after).{0,15}clearance"
+      - "new.{0,15}(?:cardiac|heart).{0,15}(?:symptom|concern|problem)"
+      - "(?:cardiac|heart).{0,15}clearance.{0,15}(?:concern|worried|changed)"
+      - "(?:chest|heart).{0,15}(?:pain|pressure|tightness|racing|pounding).{0,20}(?:since|after).{0,15}(?:cleared|clearance|cardiolog)"
+      - "(?:new|started|develop).{0,15}(?:chest|heart|cardiac).{0,15}(?:pain|symptom|problem|issue)"
+  medium:
+    phrases:
+      - "chest pain since seeing the surgeon"
+      - "heart issue since my doctor visit"
+      - "dizzy since clearance"
+      - "feeling faint since I was cleared"
+      - "lightheaded since cardiac evaluation"
+      - "new dizziness before surgery"
+      - "heart concern before my procedure"
+      - "something changed with my heart since clearance"
+      - "not feeling right since cardiac workup"
+    regex:
+      - "(?:chest|heart).{0,15}(?:since|after).{0,15}(?:surgeon|doctor|clearance)"
+      - "(?:dizzy|faint|lightheaded).{0,15}(?:since|new|recent)"
+      - "(?:something|things).{0,15}(?:changed|different).{0,15}(?:heart|chest|cardiac)"
+  low:
+    phrases:
+      - "cardiac clearance question"
+      - "heart question before surgery"
+      - "wondering about my cardiac clearance"
+      - "ask about heart before surgery"
+    regex:
+      - "cardiac clearance.{0,15}(?:question|ask|wonder)"
+      - "heart.{0,15}(?:before|prior).{0,15}surgery"
+
+negation_handling:
+  patterns:
+    - "no new symptoms since clearance"
+    - "feeling fine since cardiac clearance"
+    - "no chest pain"
+    - "no palpitations"
+    - "heart feels fine"
+    - "no issues since clearance"
+    - "cleared and feeling good"
+    - "no cardiac concerns"
+    - "heart is fine"
+    - "no dizziness"
+    - "feeling great since clearance"
+    - "no new heart problems"
+    - "cardiac clearance went well"
+    - "cardiologist said everything is fine"
+    - "no changes since clearance"
+  action: downgrade_confidence
diff --git a/list/taxonomy/pre_op_diabetes_optimization/flows/clarify_diabetes_preop.yaml b/list/taxonomy/pre_op_diabetes_optimization/flows/clarify_diabetes_preop.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..cbd000dc9705560c28f74a890f495eef0974d176
--- /dev/null
+++ b/list/taxonomy/pre_op_diabetes_optimization/flows/clarify_diabetes_preop.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify_diabetes_preop
+type: clarification
+domain: pre_op_diabetes_optimization
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: diabetes_preop_clarify
+      goal: "Ask patient to describe their diabetes concern in more detail"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - diabetes_preop_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/pre_op_diabetes_optimization/flows/escalate_diabetes_preop.yaml b/list/taxonomy/pre_op_diabetes_optimization/flows/escalate_diabetes_preop.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4fd9fac40ca7d9c161877925c54b90543df628a7
--- /dev/null
+++ b/list/taxonomy/pre_op_diabetes_optimization/flows/escalate_diabetes_preop.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_diabetes_preop
+type: escalation
+domain: pre_op_diabetes_optimization
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: diabetes_preop_escalation_notice
+      goal: "Inform patient that the surgeon and endocrine team need to be notified about diabetes management before surgery"
+      tone: calm_reassuring
+      must_include:
+        - "surgeon"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: surgical_nurse
+    urgency: same_day
+    response_spec:
+      id: diabetes_preop_escalation_handoff
+      goal: "Schedule same-day surgeon and endocrine notification about diabetes management concerns"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/pre_op_diabetes_optimization/flows/escalate_r2.yaml b/list/taxonomy/pre_op_diabetes_optimization/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b9c3a353401dc274b325f6695caed1ac9c9789a1
--- /dev/null
+++ b/list/taxonomy/pre_op_diabetes_optimization/flows/escalate_r2.yaml
@@ -0,0 +1,24 @@
+flow_id: escalate_r2
+type: escalation
+domain: pre_op_diabetes_optimization
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient about urgency of diabetes management concerns before surgery and transfer to surgical and endocrine team for same-day evaluation"
+      tone: calm_direct
+      must_include:
+        - "nurse"
+        - "right away"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably nothing"
+        - "wait and see"
+      max_questions: 0
+
+exit:
+  on_complete: handoff
diff --git a/list/taxonomy/pre_op_diabetes_optimization/flows/reassure_low_risk.yaml b/list/taxonomy/pre_op_diabetes_optimization/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a051acd4f4216f37365dea59f67da50097c6be93
--- /dev/null
+++ b/list/taxonomy/pre_op_diabetes_optimization/flows/reassure_low_risk.yaml
@@ -0,0 +1,22 @@
+flow_id: reassure_low_risk
+type: reassurance
+domain: pre_op_diabetes_optimization
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: diabetes_preop_reassure
+      goal: "Reassure the patient that their diabetes management appears adequate for surgery and provide guidance"
+      tone: warm_reassuring
+      must_include:
+        - "diabetes"
+        - "surgery"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/pre_op_diabetes_optimization/flows/screen_diabetes_preop.yaml b/list/taxonomy/pre_op_diabetes_optimization/flows/screen_diabetes_preop.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..2752039478a71c8bb782d553163fdacf3bd84061
--- /dev/null
+++ b/list/taxonomy/pre_op_diabetes_optimization/flows/screen_diabetes_preop.yaml
@@ -0,0 +1,82 @@
+flow_id: screen_diabetes_preop
+type: screening
+domain: pre_op_diabetes_optimization
+
+required_slots:
+  - glucose_level_concern
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: diabetes_preop_screen_step1
+      goal: "Ask about the patient's most recent HbA1c result"
+      tone: calm_professional
+      must_include:
+        - "A1C"
+      must_ask:
+        - "Do you know what your most recent A1C or hemoglobin A1C result was?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 1
+    collects:
+      - recent_a1c
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: diabetes_preop_screen_step2
+      goal: "Assess current blood glucose levels and recent trends"
+      tone: calm_professional
+      must_include:
+        - "blood sugar"
+      must_ask:
+        - "What have your blood sugar levels been running lately?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 1
+    collects:
+      - glucose_level_concern
+
+  - step: 3
+    type: ask
+    response_spec:
+      id: diabetes_preop_screen_step3
+      goal: "Review insulin or oral medication regimen and surgery-day instructions"
+      tone: calm_professional
+      must_include:
+        - "diabetes medication"
+      must_ask:
+        - "What diabetes medications are you on, and were you given instructions about them for the day of surgery?"
+      must_not:
+        - "don't worry"
+        - "diagnos"
+      max_questions: 2
+    collects:
+      - diabetes_medication_regimen
+      - surgery_day_diabetes_instructions
+
+  - step: 4
+    type: ask
+    response_spec:
+      id: diabetes_preop_screen_step4
+      goal: "Assess fasting glucose concerns for surgery day"
+      tone: calm_professional
+      must_include:
+        - "fasting"
+      must_ask:
+        - "Are you concerned about your blood sugar dropping too low while fasting before surgery?"
+      must_not:
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - fasting_glucose_concern
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_diabetes_preop
+  on_r3: escalate_diabetes_preop
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_diabetes_preop
diff --git a/list/taxonomy/pre_op_diabetes_optimization/rules.yaml b/list/taxonomy/pre_op_diabetes_optimization/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..13a5649d3a89af180fb5076cecc529248663b295
--- /dev/null
+++ b/list/taxonomy/pre_op_diabetes_optimization/rules.yaml
@@ -0,0 +1,33 @@
+domain: pre_op_diabetes_optimization
+target_risk_class: R2
+
+decision_rules:
+  - id: pre_op_diabetes_optimization_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: screen_diabetes_preop
+
+  - id: pre_op_diabetes_optimization_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: screen_diabetes_preop
+
+  - id: pre_op_diabetes_optimization_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify_diabetes_preop
+
+  - id: pre_op_diabetes_optimization_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_diabetes_preop
+
+  - id: pre_op_diabetes_optimization_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_diabetes_preop
diff --git a/list/taxonomy/pre_op_diabetes_optimization/triggers.yaml b/list/taxonomy/pre_op_diabetes_optimization/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6decee1a204dceeef7cbdd25e52e7736769aacc5
--- /dev/null
+++ b/list/taxonomy/pre_op_diabetes_optimization/triggers.yaml
@@ -0,0 +1,74 @@
+domain: pre_op_diabetes_optimization
+priority: 65
+
+lexical_signals:
+  high:
+    phrases:
+      - "blood sugar very high before surgery"
+      - "glucose over 300 and surgery is coming up"
+      - "uncontrolled blood sugar before my procedure"
+      - "a1c is above 9 and surgery is soon"
+      - "hemoglobin a1c is high"
+      - "insulin instructions for day of surgery"
+      - "blood sugar over 300 before surgery"
+      - "diabetes not controlled before procedure"
+      - "a1c came back at 10"
+      - "a1c above 8 and surgery is next week"
+      - "blood sugar has been running really high"
+      - "glucose uncontrolled and surgery is soon"
+      - "insulin on the morning of surgery"
+      - "diabetes and surgery day instructions"
+      - "a1c over 9 before my operation"
+    regex:
+      - "(?:blood sugar|glucose).{0,15}(?:very high|over 300|uncontrolled).{0,15}(?:before|surgery)"
+      - "(?:a1c|hemoglobin).{0,15}(?:high|above|over).{0,10}(?:8|9|10|11|12)"
+      - "(?:insulin|diabetes).{0,15}(?:day of|morning of|before).{0,15}surgery"
+      - "(?:blood sugar|glucose).{0,15}(?:over|above).{0,10}(?:300|350|400|450|500)"
+      - "(?:diabetes|diabetic).{0,15}(?:uncontrolled|not controlled|out of control).{0,15}(?:surgery|procedure|operation)"
+  medium:
+    phrases:
+      - "blood sugar and surgery"
+      - "glucose before my procedure"
+      - "diabetes and my operation"
+      - "insulin before surgery"
+      - "metformin before my procedure"
+      - "glipizide before surgery"
+      - "should I take my diabetes medication"
+      - "diabetes medication day of surgery"
+      - "blood sugar has been high"
+      - "worried about diabetes and surgery"
+      - "glucose levels before procedure"
+      - "fasting blood sugar before surgery"
+    regex:
+      - "(?:blood sugar|glucose|diabetes).{0,15}(?:surgery|procedure|operation)"
+      - "(?:insulin|metformin|glipizide).{0,15}(?:before|hold|take|day of)"
+      - "(?:should I|do I).{0,15}(?:take|hold|stop).{0,15}(?:insulin|metformin|glipizide|diabetes)"
+  low:
+    phrases:
+      - "diabetes and surgery"
+      - "diabetes before procedure"
+      - "fasting glucose morning of surgery"
+      - "glucose and my operation"
+    partials:
+      - "diabetes surgery"
+      - "glucose morning"
+      - "fasting glucose"
+
+negation_handling:
+  patterns:
+    - "blood sugar is controlled"
+    - "diabetes is well managed"
+    - "a1c is good"
+    - "glucose levels are normal"
+    - "diabetes under control"
+    - "blood sugar has been fine"
+    - "no diabetes concerns"
+    - "a1c is below 7"
+    - "diabetes is stable"
+    - "blood sugar is normal"
+    - "managing my diabetes well"
+    - "glucose has been in range"
+    - "no issues with blood sugar"
+    - "diabetes is well controlled for surgery"
+    - "endocrinologist cleared me"
+  action: downgrade_confidence
diff --git a/list/taxonomy/pre_op_medication_review/flows/clarify_medication_preop.yaml b/list/taxonomy/pre_op_medication_review/flows/clarify_medication_preop.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e41646b505c06f593fbf7944a42bfdf999532a82
--- /dev/null
+++ b/list/taxonomy/pre_op_medication_review/flows/clarify_medication_preop.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify_medication_preop
+type: clarification
+domain: pre_op_medication_review
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: med_review_clarify
+      goal: "Ask patient to describe their medication concern in more detail"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - medication_preop_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/pre_op_medication_review/flows/escalate_r2.yaml b/list/taxonomy/pre_op_medication_review/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..06a8cb1f6966bf2e4365ce99e4fc092e3768c085
--- /dev/null
+++ b/list/taxonomy/pre_op_medication_review/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: pre_op_medication_review
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: med_review_r2_escalation_notice
+      goal: "Inform patient that a nurse will follow up same day about their medication concerns"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: med_review_r2_handoff
+      goal: "Schedule same-day nurse callback with medication review context"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/pre_op_medication_review/flows/review_medications.yaml b/list/taxonomy/pre_op_medication_review/flows/review_medications.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1eff8bbe117282fb62e2a7104f869c5e148cfed3
--- /dev/null
+++ b/list/taxonomy/pre_op_medication_review/flows/review_medications.yaml
@@ -0,0 +1,82 @@
+flow_id: review_medications
+type: assessment
+domain: pre_op_medication_review
+
+required_slots:
+  - medication_list_confirmed
+  - hold_instructions_confirmed
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: med_review_step1
+      goal: "Review the patient's current medication list to identify medications relevant to surgery"
+      tone: professional_helpful
+      must_include:
+        - "medications"
+      must_ask:
+        - "Can you tell me what medications you are currently taking?"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - medication_list_confirmed
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: med_review_step2
+      goal: "Confirm which medications to hold and the timing for stopping them before surgery"
+      tone: professional_helpful
+      must_include:
+        - "hold"
+        - "stop"
+      must_ask:
+        - "Were you given instructions about which medications to stop before surgery and when?"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - hold_instructions_confirmed
+
+  - step: 3
+    type: ask
+    response_spec:
+      id: med_review_step3
+      goal: "Clarify which medications to take the morning of surgery with a sip of water"
+      tone: professional_helpful
+      must_include:
+        - "morning of surgery"
+      must_ask:
+        - "Do you know which medications you should take the morning of surgery with a small sip of water?"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - day_of_surgery_meds_confirmed
+
+  - step: 4
+    type: ask
+    response_spec:
+      id: med_review_step4
+      goal: "Confirm the patient understands all medication instructions before surgery"
+      tone: professional_helpful
+      must_include:
+        - "understand"
+      must_ask:
+        - "Do you feel clear on your medication instructions for surgery?"
+      must_not:
+        - "diagnos"
+      max_questions: 1
+    collects:
+      - medication_understanding_confirmed
+
+exit:
+  on_complete: evaluate_concern
+  on_concern: handoff
+  on_low_risk: end
+  on_unclear: handoff
diff --git a/list/taxonomy/pre_op_medication_review/rules.yaml b/list/taxonomy/pre_op_medication_review/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5c2f53f62912291860a3322bb5b88053b3a75b33
--- /dev/null
+++ b/list/taxonomy/pre_op_medication_review/rules.yaml
@@ -0,0 +1,27 @@
+domain: pre_op_medication_review
+target_risk_class: R1
+
+decision_rules:
+  - id: pre_op_medication_review_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: review_medications
+
+  - id: pre_op_medication_review_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: review_medications
+
+  - id: pre_op_medication_review_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify_medication_preop
+
+  - id: pre_op_medication_review_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/pre_op_medication_review/triggers.yaml b/list/taxonomy/pre_op_medication_review/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..13481f4e82ca623e71c6e87ee04d6ae3f3ad470f
--- /dev/null
+++ b/list/taxonomy/pre_op_medication_review/triggers.yaml
@@ -0,0 +1,67 @@
+domain: pre_op_medication_review
+priority: 50
+
+lexical_signals:
+  high:
+    phrases:
+      - "which medications do I stop before surgery"
+      - "what pills should I hold before my procedure"
+      - "medication instructions for surgery"
+      - "which drugs do I skip before the operation"
+      - "medication review before surgery"
+      - "what medications do I take before my procedure"
+      - "need my medication list reviewed for surgery"
+      - "which medicine should I stop before my operation"
+      - "medication instructions before my procedure"
+      - "what pills do I hold before surgery"
+      - "which medications to stop for my operation"
+      - "pre-surgery medication instructions"
+      - "medication list for surgery day"
+      - "which meds to take day of surgery"
+    regex:
+      - "(?:which|what).{0,15}(?:medication|medicine|pill|drug).{0,15}(?:stop|hold|take|skip).{0,15}(?:before|surgery|procedure)"
+      - "medication.{0,15}(?:instruction|list|review).{0,15}(?:before|surgery|pre)"
+      - "(?:which|what).{0,15}(?:med|pill|drug).{0,15}(?:day of|morning of).{0,10}surgery"
+  medium:
+    phrases:
+      - "stop my medication before surgery"
+      - "hold my medicine"
+      - "continue my pills before the procedure"
+      - "blood thinner before surgery"
+      - "aspirin before my procedure"
+      - "metformin before surgery"
+      - "insulin day of surgery"
+      - "should I take my blood pressure medicine"
+      - "medication and surgery question"
+      - "confused about my medications for surgery"
+      - "not sure which meds to take"
+      - "bring my medications to surgery"
+    regex:
+      - "(?:stop|hold|continue).{0,15}(?:medication|medicine|pill)"
+      - "(?:blood thinner|aspirin|metformin|insulin).{0,15}(?:before|surgery|day of)"
+      - "(?:should I|do I).{0,15}(?:take|stop|hold|skip).{0,15}(?:medication|medicine|pill)"
+  low:
+    partials:
+      - "medication before surgery"
+      - "medicine and procedure"
+      - "pills before operation"
+      - "take my medication"
+      - "bring my medications"
+
+negation_handling:
+  patterns:
+    - "already reviewed my medications"
+    - "know which medications to stop"
+    - "got my medication instructions"
+    - "medication list is ready"
+    - "no medication questions"
+    - "understand my medication instructions"
+    - "already talked about medications"
+    - "clear on my med instructions"
+    - "nurse already went over medications"
+    - "pharmacist reviewed my medications"
+    - "no questions about my pills"
+    - "all set with medications"
+    - "medication instructions are clear"
+    - "know what to take and what to hold"
+  action: downgrade_confidence
diff --git a/list/taxonomy/pre_op_osa_screening/flows/clarify_osa.yaml b/list/taxonomy/pre_op_osa_screening/flows/clarify_osa.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..cac9b389d6017b9ee41cbbf879d54a94393e262b
--- /dev/null
+++ b/list/taxonomy/pre_op_osa_screening/flows/clarify_osa.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify_osa
+type: clarification
+domain: pre_op_osa_screening
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: osa_clarify
+      goal: "Ask patient to describe their sleep concern in more detail"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - osa_concern_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/pre_op_osa_screening/flows/escalate_r2.yaml b/list/taxonomy/pre_op_osa_screening/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c552dc38320f997da3d9a6667627aaf842c802bc
--- /dev/null
+++ b/list/taxonomy/pre_op_osa_screening/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: pre_op_osa_screening
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: osa_r2_escalation_notice
+      goal: "Inform patient that the anesthesia team will be notified about sleep apnea screening results before surgery"
+      tone: calm_reassuring
+      must_include:
+        - "anesthesia team"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: anesthesia_team
+    urgency: same_day
+    response_spec:
+      id: osa_r2_handoff
+      goal: "Schedule same-day anesthesia team notification with OSA screening results"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/pre_op_osa_screening/flows/reassure_low_risk.yaml b/list/taxonomy/pre_op_osa_screening/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e0d7ad286d67b41e134af037d07e97b177d40701
--- /dev/null
+++ b/list/taxonomy/pre_op_osa_screening/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: reassurance
+domain: pre_op_osa_screening
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: osa_reassure
+      goal: "Reassure the patient that their sleep apnea screening results are low risk and provide guidance about CPAP use"
+      tone: warm_reassuring
+      must_include:
+        - "sleep"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/pre_op_osa_screening/flows/screen_osa.yaml b/list/taxonomy/pre_op_osa_screening/flows/screen_osa.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1fba922aca65e43ef7eb22aa09a9b4dc5468127a
--- /dev/null
+++ b/list/taxonomy/pre_op_osa_screening/flows/screen_osa.yaml
@@ -0,0 +1,150 @@
+flow_id: screen_osa
+type: screening
+domain: pre_op_osa_screening
+
+required_slots:
+  - snoring
+  - observed_apnea
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: osa_screen_step1
+      goal: "STOP-BANG screening: assess for loud snoring"
+      tone: warm_professional
+      must_include:
+        - "snoring"
+      must_ask:
+        - "Do you snore loudly, loud enough to be heard through closed doors?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 1
+    collects:
+      - snoring
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: osa_screen_step2
+      goal: "STOP-BANG screening: assess for daytime tiredness and fatigue"
+      tone: warm_professional
+      must_include:
+        - "tired"
+      must_ask:
+        - "Do you often feel tired, fatigued, or sleepy during the daytime?"
+      must_not:
+        - "don't worry"
+        - "that's normal"
+      max_questions: 1
+    collects:
+      - daytime_tiredness
+
+  - step: 3
+    type: ask
+    response_spec:
+      id: osa_screen_step3
+      goal: "STOP-BANG screening: assess for observed apnea episodes during sleep"
+      tone: warm_professional
+      must_include:
+        - "breathing"
+      must_ask:
+        - "Has anyone ever observed you stop breathing or choke during your sleep?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 1
+    collects:
+      - observed_apnea
+
+  - step: 4
+    type: ask
+    response_spec:
+      id: osa_screen_step4
+      goal: "STOP-BANG screening: assess for treated hypertension"
+      tone: warm_professional
+      must_include:
+        - "blood pressure"
+      must_ask:
+        - "Are you being treated for high blood pressure?"
+      must_not:
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - hypertension_treated
+
+  - step: 5
+    type: ask
+    response_spec:
+      id: osa_screen_step5
+      goal: "STOP-BANG screening: assess BMI above 35"
+      tone: warm_professional
+      must_include:
+        - "weight"
+      must_ask:
+        - "Has your doctor mentioned concerns about your weight or BMI?"
+      must_not:
+        - "overweight"
+        - "obese"
+        - "judgmental"
+      max_questions: 1
+    collects:
+      - bmi_elevated
+
+  - step: 6
+    type: ask
+    response_spec:
+      id: osa_screen_step6
+      goal: "STOP-BANG screening: assess age over 50"
+      tone: warm_professional
+      must_include:
+        - "age"
+      must_ask:
+        - "Are you over 50 years old?"
+      must_not:
+        - "don't worry"
+        - "that's fine"
+      max_questions: 1
+    collects:
+      - age_over_50
+
+  - step: 7
+    type: ask
+    response_spec:
+      id: osa_screen_step7
+      goal: "STOP-BANG screening: assess neck circumference"
+      tone: warm_professional
+      must_include:
+        - "neck"
+      must_ask:
+        - "Has anyone mentioned you have a large neck circumference, or do you wear a collar size 17 inches or larger?"
+      must_not:
+        - "don't worry"
+        - "that's fine"
+      max_questions: 1
+    collects:
+      - neck_circumference_elevated
+
+  - step: 8
+    type: ask
+    response_spec:
+      id: osa_screen_step8
+      goal: "STOP-BANG screening: assess gender as male (risk factor)"
+      tone: warm_professional
+      must_include:
+        - "gender"
+      must_ask:
+        - "For this screening, I need to note your gender. Are you male?"
+      must_not:
+        - "don't worry"
+        - "judgmental"
+      max_questions: 1
+    collects:
+      - gender_male
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_low_risk: reassure_low_risk
+  on_unclear: handoff
diff --git a/list/taxonomy/pre_op_osa_screening/rules.yaml b/list/taxonomy/pre_op_osa_screening/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3c645d8f3b36a8709d44bd37f589dcfa41f0045f
--- /dev/null
+++ b/list/taxonomy/pre_op_osa_screening/rules.yaml
@@ -0,0 +1,27 @@
+domain: pre_op_osa_screening
+target_risk_class: R1
+
+decision_rules:
+  - id: pre_op_osa_screening_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: screen_osa
+
+  - id: pre_op_osa_screening_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: screen_osa
+
+  - id: pre_op_osa_screening_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify_osa
+
+  - id: pre_op_osa_screening_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/pre_op_osa_screening/triggers.yaml b/list/taxonomy/pre_op_osa_screening/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ab0976fc855401abf8ac0bb9c4252013344e6214
--- /dev/null
+++ b/list/taxonomy/pre_op_osa_screening/triggers.yaml
@@ -0,0 +1,74 @@
+domain: pre_op_osa_screening
+priority: 44
+
+lexical_signals:
+  high:
+    phrases:
+      - "snoring and have surgery coming up"
+      - "sleep apnea before surgery"
+      - "use a cpap and having surgery"
+      - "bipap and surgery"
+      - "stop breathing at night"
+      - "apnea during sleep"
+      - "sleep apnea and anesthesia"
+      - "cpap machine and surgery"
+      - "diagnosed with sleep apnea"
+      - "use cpap every night and have surgery"
+      - "sleep apnea not treated"
+      - "snoring loudly and surgery is soon"
+      - "stop breathing when I sleep and having a procedure"
+      - "sleep apnea before my operation"
+      - "cpap for surgery"
+    regex:
+      - "(?:snoring|sleep apnea|cpap|bipap).{0,15}(?:surgery|anesthesia|procedure)"
+      - "(?:stop breathing|apnea).{0,15}(?:sleep|night)"
+      - "(?:cpap|bipap).{0,15}(?:surgery|procedure|bring|use)"
+      - "(?:sleep apnea|osa).{0,15}(?:before|and|with).{0,10}(?:surgery|procedure|anesthesia)"
+  medium:
+    phrases:
+      - "snore really loud"
+      - "partner says I snore"
+      - "spouse says I stop breathing"
+      - "heavy snoring"
+      - "tired all the time during the day"
+      - "always sleepy during the day"
+      - "excessive daytime fatigue"
+      - "can't stay awake during the day"
+      - "fall asleep during the day"
+      - "snoring worse lately"
+      - "told I snore very loud"
+    regex:
+      - "(?:snore|snoring).{0,15}(?:loud|heavy|partner|spouse)"
+      - "(?:tired|sleepy|fatigue).{0,15}(?:daytime|during the day|always)"
+      - "(?:fall asleep|can't stay awake).{0,15}(?:during the day|daytime|at work)"
+  low:
+    phrases:
+      - "sleep problem before surgery"
+      - "sleep issue and procedure"
+      - "sleep concern before surgery"
+      - "should I bring my cpap"
+      - "cpap to the hospital"
+    partials:
+      - "sleep problem"
+      - "sleep apnea"
+      - "cpap"
+      - "snoring"
+
+negation_handling:
+  patterns:
+    - "don't snore"
+    - "no sleep apnea"
+    - "sleep fine"
+    - "no snoring"
+    - "don't use a cpap"
+    - "no breathing problems at night"
+    - "sleep well"
+    - "no daytime sleepiness"
+    - "not tired during the day"
+    - "partner says I don't snore"
+    - "no sleep issues"
+    - "sleep apnea test was negative"
+    - "no apnea"
+    - "don't stop breathing at night"
+    - "sleep study was normal"
+  action: downgrade_confidence
diff --git a/list/taxonomy/pre_op_smoking_cessation/flows/assess_smoking_status.yaml b/list/taxonomy/pre_op_smoking_cessation/flows/assess_smoking_status.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..03b54429b560aabc1a91038ebb59519878bce802
--- /dev/null
+++ b/list/taxonomy/pre_op_smoking_cessation/flows/assess_smoking_status.yaml
@@ -0,0 +1,82 @@
+flow_id: assess_smoking_status
+type: assessment
+domain: pre_op_smoking_cessation
+
+required_slots:
+  - current_smoker
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: smoking_assess_step1
+      goal: "Determine the patient's current smoking or vaping status and quantity"
+      tone: nonjudgmental_professional
+      must_include:
+        - "smoking"
+      must_ask:
+        - "Are you currently smoking or vaping? If so, how much per day?"
+      must_not:
+        - "you should have quit"
+        - "that's bad"
+        - "judgmental"
+      max_questions: 1
+    collects:
+      - current_smoker
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: smoking_assess_step2
+      goal: "Assess quit attempts and timeline relative to surgery date"
+      tone: nonjudgmental_professional
+      must_include:
+        - "quit"
+      must_ask:
+        - "Have you tried to cut back or quit? When is your surgery scheduled?"
+      must_not:
+        - "you should have"
+        - "too late"
+      max_questions: 2
+    collects:
+      - quit_attempt_history
+      - surgery_timeline
+
+  - step: 3
+    type: ask
+    response_spec:
+      id: smoking_assess_step3
+      goal: "Assess the patient's interest in cessation support resources"
+      tone: nonjudgmental_professional
+      must_include:
+        - "help"
+      must_ask:
+        - "Would you be interested in any support to help with quitting, such as nicotine patches or a quitline?"
+      must_not:
+        - "you must quit"
+        - "your fault"
+      max_questions: 1
+    collects:
+      - cessation_interest
+
+  - step: 4
+    type: respond
+    response_spec:
+      id: smoking_assess_step4
+      goal: "Provide pre-surgical cessation recommendations and explain impact on healing"
+      tone: nonjudgmental_professional
+      must_include:
+        - "healing"
+        - "surgery"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "you should have"
+      max_questions: 0
+
+exit:
+  on_complete: evaluate_concern
+  on_concern: handoff
+  on_low_risk: end
+  on_unclear: handoff
diff --git a/list/taxonomy/pre_op_smoking_cessation/flows/clarify_smoking.yaml b/list/taxonomy/pre_op_smoking_cessation/flows/clarify_smoking.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a9b6816e9d9981950912080ac41c6e15be7ee8af
--- /dev/null
+++ b/list/taxonomy/pre_op_smoking_cessation/flows/clarify_smoking.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify_smoking
+type: clarification
+domain: pre_op_smoking_cessation
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: smoking_clarify
+      goal: "Ask patient to describe their smoking or tobacco concern in more detail"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - smoking_concern_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/pre_op_smoking_cessation/flows/escalate_r2.yaml b/list/taxonomy/pre_op_smoking_cessation/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4fa2947038438cec1147f8a43932c61434cbaa82
--- /dev/null
+++ b/list/taxonomy/pre_op_smoking_cessation/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: pre_op_smoking_cessation
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: smoking_r2_escalation_notice
+      goal: "Inform patient that a nurse will follow up about smoking cessation support before surgery"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: smoking_r2_handoff
+      goal: "Schedule same-day nurse callback with smoking cessation context"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/pre_op_smoking_cessation/rules.yaml b/list/taxonomy/pre_op_smoking_cessation/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..2d10138fc35720896bac8c4694e242fad450a622
--- /dev/null
+++ b/list/taxonomy/pre_op_smoking_cessation/rules.yaml
@@ -0,0 +1,27 @@
+domain: pre_op_smoking_cessation
+target_risk_class: R1
+
+decision_rules:
+  - id: pre_op_smoking_cessation_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: assess_smoking_status
+
+  - id: pre_op_smoking_cessation_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: assess_smoking_status
+
+  - id: pre_op_smoking_cessation_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify_smoking
+
+  - id: pre_op_smoking_cessation_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/pre_op_smoking_cessation/triggers.yaml b/list/taxonomy/pre_op_smoking_cessation/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..aaa8c78bc92984961c000d6964525b283602b8ab
--- /dev/null
+++ b/list/taxonomy/pre_op_smoking_cessation/triggers.yaml
@@ -0,0 +1,71 @@
+domain: pre_op_smoking_cessation
+priority: 42
+
+lexical_signals:
+  high:
+    phrases:
+      - "still smoking before surgery"
+      - "currently smoking and surgery is coming up"
+      - "can't quit smoking before my procedure"
+      - "still vaping before surgery"
+      - "unable to stop smoking before my operation"
+      - "smoking a pack a day and surgery is soon"
+      - "haven't been able to quit smoking"
+      - "still smoking cigarettes before the procedure"
+      - "tried to quit smoking but couldn't"
+      - "still using cigarettes before surgery"
+      - "quit smoking but started again before surgery"
+      - "vaping every day and surgery is next week"
+      - "couldn't stop smoking in time for surgery"
+    regex:
+      - "(?:still|currently).{0,15}(?:smoking|smoke|cigarette|vape|vaping)"
+      - "(?:quit|stop).{0,15}(?:smoking|cigarette).{0,15}(?:before|surgery|can't|unable)"
+      - "(?:can't|cannot|unable|couldn't).{0,15}(?:quit|stop).{0,15}(?:smoking|smoke|cigarette|vape)"
+  medium:
+    phrases:
+      - "smoking and having surgery"
+      - "cigarettes before my procedure"
+      - "tobacco use before surgery"
+      - "vaping before my operation"
+      - "how long to quit smoking before surgery"
+      - "when should I stop smoking before my procedure"
+      - "smoking and anesthesia"
+      - "does smoking affect my surgery"
+      - "smoke occasionally before surgery"
+      - "cut down on smoking before procedure"
+    regex:
+      - "(?:smoke|smoking|cigarette|tobacco|vape).{0,15}(?:surgery|procedure|operation)"
+      - "(?:how long|when).{0,15}(?:quit|stop).{0,15}(?:smoking|smoke).{0,15}(?:before|prior)"
+      - "(?:does|will|can).{0,15}(?:smoking|smoke|cigarette).{0,15}(?:affect|impact|problem).{0,10}(?:surgery|procedure|healing)"
+  low:
+    phrases:
+      - "smoking question"
+      - "smoking concern"
+      - "nicotine patch before surgery"
+      - "nicotine gum before procedure"
+    partials:
+      - "smoking question"
+      - "nicotine patch"
+      - "smoking concern"
+      - "tobacco cessation"
+
+negation_handling:
+  patterns:
+    - "quit smoking"
+    - "stopped smoking"
+    - "don't smoke"
+    - "never smoked"
+    - "not a smoker"
+    - "gave up cigarettes"
+    - "haven't smoked in years"
+    - "quit vaping"
+    - "no tobacco use"
+    - "smoke-free"
+    - "stopped smoking weeks ago"
+    - "quit before surgery as told"
+    - "haven't had a cigarette"
+    - "non-smoker"
+    - "quit months ago"
+    - "no smoking"
+    - "kicked the habit"
+  action: downgrade_confidence
diff --git a/list/taxonomy/pregnancy_emergency/flows/clarify.yaml b/list/taxonomy/pregnancy_emergency/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..62aec608eda11d92f553ad13adb5a6034d871476
--- /dev/null
+++ b/list/taxonomy/pregnancy_emergency/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: pregnancy_emergency
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: pregnancy_emergency_clarify
+      goal: "Ask patient to describe their pregnancy emergency symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - pregnancy_emergency_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/pregnancy_emergency/flows/escalate_r3.yaml b/list/taxonomy/pregnancy_emergency/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8e6e4b417915a6b865868746b30e9a38120f095d
--- /dev/null
+++ b/list/taxonomy/pregnancy_emergency/flows/escalate_r3.yaml
@@ -0,0 +1,38 @@
+flow_id: escalate_r3
+type: escalation
+domain: pregnancy_emergency
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Inform patient this requires immediate clinical attention and they will
+      be transferred
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/pregnancy_emergency/flows/handoff.yaml b/list/taxonomy/pregnancy_emergency/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1daf9986d4b0aa2fc9b702a147166d0afe149237
--- /dev/null
+++ b/list/taxonomy/pregnancy_emergency/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: pregnancy_emergency
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: pregnancy_emergency_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: pregnancy_emergency_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/pregnancy_emergency/rules.yaml b/list/taxonomy/pregnancy_emergency/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3b49470277d634d3e5ec17ac635dfc940413f68f
--- /dev/null
+++ b/list/taxonomy/pregnancy_emergency/rules.yaml
@@ -0,0 +1,21 @@
+domain: pregnancy_emergency
+target_risk_class: R3
+
+decision_rules:
+  - id: pregnancy_emergency_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r3
+
+  - id: pregnancy_emergency_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r3
+
+  - id: pregnancy_emergency_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/pregnancy_emergency/triggers.yaml b/list/taxonomy/pregnancy_emergency/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..130b60aa113879e867daa59fc45a98a94938358f
--- /dev/null
+++ b/list/taxonomy/pregnancy_emergency/triggers.yaml
@@ -0,0 +1,288 @@
+domain: pregnancy_emergency
+priority: 88
+
+lexical_signals:
+  high:
+    phrases:
+      - "pregnant and bleeding heavily"
+      - "pregnant and fainted"
+      - "pregnancy bleeding"
+      - "heavy vaginal bleeding and pregnant"
+      - "pregnant and passed out"
+      - "pregnant and hemorrhaging"
+      - "pregnant and something's wrong"
+      - "weeks pregnant and bleeding"
+      - "pregnant and cramping badly"
+      - "she's pregnant"
+      # --- caregiver-reported patterns (high confidence) ---
+      - "my wife is pregnant and bleeding"
+      - "my girlfriend is pregnant and bleeding"
+      - "she's bleeding a lot"
+      - "her water broke"
+      - "she's having contractions"
+      - "she can't stop bleeding"
+      - "she's in so much pain"
+      - "something's wrong with my wife"
+      - "something's wrong with my girlfriend"
+      # --- severe symptom combos (high confidence) ---
+      - "pregnant and soaking through pads"
+      - "pregnant and can't stop bleeding"
+      - "pregnant and seeing spots"
+      - "pregnant and terrible headache"
+      - "pregnant and really swollen"
+      - "pregnant and passing clots"
+      - "baby isn't moving at all"
+      - "baby stopped moving"
+      - "no fetal movement"
+      - "baby hasn't moved"
+    regex:
+      - "pregnant\\s+and\\s+(bleeding|faint|passed\\s+out|cramping)"
+      - "\\d+\\s*weeks?\\s+pregnant"
+      - "\\d+\\s*weeks.{0,80}(bleed|cramp|pain|pressure|gush|fluid|contraction|blood)"
+      - "(bleed|cramp|pain|pressure|gush|fluid|contraction|blood).{0,80}\\d+\\s*weeks"
+      - "pregnant.{0,80}bleed"
+      - "bleed.{0,80}pregnant"
+      - "pregnant.{0,80}cramp"
+      - "pregnant.{0,80}(pain|hurt|ache)"
+      - "pregnant.{0,80}(dizzy|faint|passed out|lightheaded)"
+      - "pregnant.{0,80}headache"
+      - "pregnant.{0,80}(swelling|swollen)"
+      - "pregnant.{0,80}(gush|blood|soaking)"
+      - "trimester"
+      - "\\d+\\s*weeks.{0,15}(and|but|,)"
+      - "she'?s\\s+pregnant"
+      - "i'?m\\s+pregnant"
+      # --- caregiver-reported regex (high confidence) ---
+      - "(my\\s+)?(wife|girlfriend|partner|daughter).{0,50}pregnant.{0,50}(bleed|blood|wrong|pain|dizzy|faint)"
+      - "she'?s.{0,40}(bleeding|hemorrhag|contraction|labor|passed\\s+out|faint)"
+      - "her\\s+(water|membranes?).{0,15}(broke|ruptured)"
+      # --- reduced fetal movement (high confidence) ---
+      - "baby.{0,40}(not|hasn't|stopped|quit).{0,20}mov"
+      - "baby.{0,40}(hasn't|not).{0,20}(kick|moved)"
+      - "(haven't|hasn't|not|didn't).{0,30}felt.{0,20}(baby|kick|movement)"
+      - "fetal\\s+movement.{0,25}(decreased|reduced|less|none|stopped)"
+      # --- preeclampsia high confidence signals ---
+      - "pregnant.{0,60}(vision|seeing|see).{0,40}(spot|spark|blur|flash|zig|double)"
+      - "pregnant.{0,60}(severe|terrible|worst|intense|splitting)\\s+headache"
+      - "(\\d+\\s*weeks).{0,60}headache.{0,60}(swol|puff|vision|blur)"
+      # --- bright red / clot bleeding ---
+      - "(bright\\s+red|fresh).{0,30}(blood|bleed).{0,50}pregnant"
+      - "pregnant.{0,50}(bright\\s+red|fresh).{0,30}(blood|bleed)"
+      - "passing.{0,20}clots?.{0,40}pregnant"
+      - "pregnant.{0,40}passing.{0,20}clots?"
+  medium:
+    phrases:
+      - "bleeding during pregnancy"
+      - "pregnant and dizzy"
+      - "pregnancy complication"
+      - "vaginal bleeding while pregnant"
+      - "contractions too early"
+      - "baby isn't moving"
+      - "water broke early"
+      - "leaking fluid and pregnant"
+      - "preeclampsia"
+      - "pregnant and my blood pressure is high"
+      - "really pregnant"
+      - "belly feels tight"
+      - "eight months pregnant"
+      - "eight months along"
+      - "gush of blood"
+      # --- Phase 4: expanded patterns for missed scenarios ---
+      - "lady problems"
+      - "female issue"
+      - "women's trouble"
+      - "spotting and cramping"
+      - "soaked through pads"
+      - "going through pads quickly"
+      # --- Phase 5: additional vaginal bleeding patterns ---
+      - "bleeding more than spotting"
+      - "bleeding won't stop"
+      - "bleeding keeps coming"
+      - "changed pads twice"
+      - "changed pads three times"
+      - "pad is getting full"
+      - "pad soaked in an hour"
+      - "blood when I wipe"
+      - "blood on my underwear"
+      - "clots in the toilet"
+      - "thicker bits"
+      - "bright red blood"
+      # --- reduced fetal movement variations ---
+      - "baby's been quieter"
+      - "baby is quieter"
+      - "baby has been quiet"
+      - "less movement than usual"
+      - "movement has decreased"
+      - "baby moving less"
+      - "baby not as active"
+      - "baby hasn't kicked"
+      - "haven't felt movement"
+      - "not feeling movement"
+      - "the baby's quiet"
+      # --- preterm labor signals ---
+      - "contractions coming"
+      - "timing contractions"
+      - "contractions every few minutes"
+      - "cramping comes and goes"
+      - "tightening comes and goes"
+      - "regular cramping"
+      - "regular tightening"
+      - "preterm labor"
+      - "premature contractions"
+      # --- preeclampsia signals ---
+      - "rings don't fit"
+      - "wedding ring won't come off"
+      - "face is puffy"
+      - "face looks puffy"
+      - "hands are swollen"
+      - "feet are swollen"
+      - "ankles are swollen"
+      - "vision is blurry"
+      - "seeing sparkly things"
+      - "seeing spots"
+      - "sparkly zigzags"
+      - "flashing lights"
+      - "blood pressure is high"
+      - "bp is high"
+      - "high blood pressure and pregnant"
+      - "headache won't go away"
+      - "worst headache"
+      - "terrible headache"
+      - "splitting headache"
+      - "pain under my ribs"
+      - "upper belly pain"
+      - "right sided belly pain"
+      # --- caregiver patterns medium ---
+      - "my wife is bleeding"
+      - "my girlfriend is bleeding"
+      - "my partner is bleeding"
+      - "she keeps bleeding"
+      - "she's been bleeding"
+      - "she's still bleeding"
+      - "she's in pain"
+      - "she's scared"
+      - "she's really worried"
+      - "calling about my wife"
+      - "calling about my girlfriend"
+      - "calling about my partner"
+      # --- euphemistic patterns ---
+      - "lady issues"
+      - "women's issues"
+      - "down there problems"
+      - "feminine problems"
+      - "private area bleeding"
+    regex:
+      - "(baby|fetus).{0,30}(not moving|stopped moving|less movement|moving less)"
+      - "(water|membrane).{0,20}(broke|ruptured|leaking)"
+      - "(gush|sudden).{0,15}(blood|bleed|fluid)"
+      - "(belly|abdomen|stomach).{0,20}(tight|hard|cramping|contracting)"
+      - "really\\s+(far along|pregnant)"
+      - "eight\\s+months\\s+(pregnant|along|preg)"
+      - "\\b(2[0-9]|3[0-9]|4[0-2])\\s*weeks\\b"
+      - "placenta\\s+(previa|abruption|accreta)"
+      - "braxton\\s+hicks.{0,40}(real|actual|not sure|can't tell)"
+      # --- Phase 4: expanded patterns for missed scenarios ---
+      - "(lady|women's|female).{0,10}(problem|issue|trouble)"
+      - "pregnant.{0,40}(seeing|see|vision).{0,20}(sparkle|flash|spot|aura|blur)"
+      - "\\b(ring|rings).{0,20}(don't fit|too tight|too small|won't come off)"
+      - "(went|gone|going).{0,30}(through|using).{0,10}\\d+.{0,5}pad"
+      - "(soak|soaked|soaking).{0,20}(pad|pads|through)"
+      - "probably.{0,30}(nothing|fine).{0,30}(spotting|bleed|cramp)"
+      # --- Phase 5: reduced fetal movement ---
+      - "baby.{0,40}(quieter|quiet|less active|decreased|reduced)"
+      - "baby.{0,40}hasn.{0,10}(moved|kicked|active)"
+      - "(felt|feel|feeling).{0,20}less.{0,20}(movement|kick|active)"
+      - "movement.{0,30}(decreased|reduced|less|quieter)"
+      - "haven.{0,10}felt.{0,30}(move|kick|baby)"
+      # --- preterm labor patterns ---
+      - "contraction.{0,30}(every|regular|coming|started)"
+      - "cramp.{0,30}(every|regular|comes and goes|timing)"
+      - "tighten.{0,30}(every|regular|comes and goes|lets go)"
+      - "(timing|time|counting).{0,20}(contraction|cramp)"
+      # --- preeclampsia variations ---
+      - "(ring|rings).{0,30}(tight|fit|off)"
+      - "(face|hands|feet|ankles).{0,20}(puffy|swollen|swelling)"
+      - "(puffy|swollen|swelling).{0,20}(face|hands|feet|ankles)"
+      - "vision.{0,30}(blur|spark|flash|spot|double|weird)"
+      - "(blur|spark|flash|spot|double|weird).{0,30}vision"
+      - "headache.{0,40}pregnant"
+      - "pregnant.{0,40}headache"
+      - "(pain|ache).{0,20}(rib|right side|upper abdomen)"
+      # --- caregiver regex patterns ---
+      - "(wife|girlfriend|partner|daughter).{0,40}(bleed|blood|pain|cramp|contraction)"
+      - "(calling|call).{0,20}about.{0,20}(wife|girlfriend|partner|daughter|her)"
+      - "she.{0,30}(bleed|blood|cramp|contraction|pain|labor)"
+      # --- gestational age patterns ---
+      - "\\d+\\s*months?\\s+(pregnant|along)"
+      - "(six|seven|eight|nine)\\s+months?\\s+(pregnant|along)"
+      - "due\\s+(date|in).{0,20}(weeks?|months?)"
+      - "expecting.{0,30}(bleed|cramp|pain|dizzy)"
+  low:
+    partials:
+      - "pregnancy bleeding"
+      - "pregnant complication"
+      - "obstetric"
+      - "preeclampsia"
+      - "eclampsia"
+      - "placenta"
+      - "premature labor"
+      - "weeks pregnant"
+      - "months pregnant"
+      - "I'm pregnant"
+      # --- Phase 5: additional low confidence partials ---
+      - "she's pregnant"
+      - "expecting"
+      - "due date"
+      - "fetal"
+      - "baby moving"
+      - "baby kicking"
+      - "third trimester"
+      - "second trimester"
+      - "first trimester"
+      - "gestational"
+      - "prenatal"
+      - "miscarriage"
+      - "contractions"
+      - "water broke"
+      - "amniotic"
+      - "spotting"
+      - "vaginal bleeding"
+      - "cramping and pregnant"
+
+negation_handling:
+  patterns:
+    - "not pregnant"
+    - "no pregnancy complications"
+    - "pregnancy is fine"
+    # --- follow-up/scheduling timeframe context (R1 scenarios) ---
+    - "follow up in"
+    - "follow-up in"
+    - "return in"
+    - "appointment in"
+    - "check back in"
+    - "see you in"
+    - "come back in"
+    - "weeks from now"
+    - "weeks out"
+    - "weeks post"
+    - "weeks since"
+    - "weeks ago"
+    - "days from now"
+    - "days ago"
+    - "weeks after surgery"
+    - "weeks after the procedure"
+    - "week follow-up"
+    - "week follow up"
+    - "week check"
+    - "week appointment"
+    - "post-op"
+    - "post-procedure"
+    - "recovery timeline"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
diff --git a/list/taxonomy/procedure_anxiety_severe/flows/clarify.yaml b/list/taxonomy/procedure_anxiety_severe/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d2001f052a28c7f06b9cd74060c2c876e3e93c41
--- /dev/null
+++ b/list/taxonomy/procedure_anxiety_severe/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: procedure_anxiety_severe
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: procedure_anxiety_clarify
+      goal: "Ask patient to describe how they are feeling about their upcoming surgery"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - procedure_anxiety_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/procedure_anxiety_severe/flows/concern_assessment.yaml b/list/taxonomy/procedure_anxiety_severe/flows/concern_assessment.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f09400c7cf555d04b28e79f64e68f01a85aa7f8d
--- /dev/null
+++ b/list/taxonomy/procedure_anxiety_severe/flows/concern_assessment.yaml
@@ -0,0 +1,53 @@
+flow_id: concern_assessment
+type: assessment
+domain: procedure_anxiety_severe
+
+required_slots:
+  - anxiety_severity
+  - cancellation_intent
+  - support_system
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: procedure_anxiety_assess_step1
+      goal: "Understand how severe the patient's anxiety is and whether they are considering cancelling"
+      tone: warm_empathetic
+      must_include:
+        - "understand"
+      must_ask:
+        - "How would you describe how anxious you are feeling right now?"
+        - "Are you thinking about cancelling or postponing the surgery?"
+      must_not:
+        - "overreacting"
+        - "don't worry"
+        - "it's nothing"
+      max_questions: 2
+    collects:
+      - anxiety_severity
+      - cancellation_intent
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: procedure_anxiety_assess_step2
+      goal: "Assess whether the patient has support and what specific concerns are driving the anxiety"
+      tone: warm_empathetic
+      must_include:
+        - "support"
+      must_ask:
+        - "Do you have someone with you or someone you can talk to about this?"
+      must_not:
+        - "overreacting"
+        - "shouldn't feel"
+        - "it's routine"
+      max_questions: 1
+    collects:
+      - support_system
+
+exit:
+  on_complete: evaluate_concern
+  on_concern: handoff
+  on_low_risk: reassure_low_risk
+  on_unclear: handoff
diff --git a/list/taxonomy/procedure_anxiety_severe/flows/escalate_r2.yaml b/list/taxonomy/procedure_anxiety_severe/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c98439826a112f45dbdc6c8ed064b84491f73cb2
--- /dev/null
+++ b/list/taxonomy/procedure_anxiety_severe/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: procedure_anxiety_severe
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: procedure_anxiety_r2_escalation_notice
+      goal: "Inform patient that a nurse will follow up same day about their concerns"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: procedure_anxiety_r2_handoff
+      goal: "Schedule same-day nurse callback with anxiety context"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/procedure_anxiety_severe/flows/handoff.yaml b/list/taxonomy/procedure_anxiety_severe/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b5e720a03613577a3779fc280bb000cab44b0b37
--- /dev/null
+++ b/list/taxonomy/procedure_anxiety_severe/flows/handoff.yaml
@@ -0,0 +1,35 @@
+flow_id: handoff
+type: handoff
+domain: procedure_anxiety_severe
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: procedure_anxiety_handoff
+      goal: "Let patient know they will be connected with a surgical counselor who can help address their concerns"
+      tone: warm_empathetic
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+        - "overreacting"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: surgical_counselor
+    urgency: normal
+    response_spec:
+      id: procedure_anxiety_handoff_transfer
+      goal: "Transfer to surgical counselor with anxiety context"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/procedure_anxiety_severe/flows/reassure_low_risk.yaml b/list/taxonomy/procedure_anxiety_severe/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..acf9fa684488134509097ea13e2ef08a3c2ab360
--- /dev/null
+++ b/list/taxonomy/procedure_anxiety_severe/flows/reassure_low_risk.yaml
@@ -0,0 +1,22 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: procedure_anxiety_severe
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: procedure_anxiety_reassure
+      goal: "Acknowledge the patient's normal pre-surgical anxiety, validate their feelings, and note their care team will be available"
+      tone: warm_empathetic
+      must_include:
+        - "normal"
+        - "care team"
+      must_not:
+        - "emergency"
+        - "overreacting"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/procedure_anxiety_severe/rules.yaml b/list/taxonomy/procedure_anxiety_severe/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9d3442c06ee22794ea941683b3707739d395c352
--- /dev/null
+++ b/list/taxonomy/procedure_anxiety_severe/rules.yaml
@@ -0,0 +1,27 @@
+domain: procedure_anxiety_severe
+target_risk_class: R1
+
+decision_rules:
+  - id: procedure_anxiety_severe_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: concern_assessment
+
+  - id: procedure_anxiety_severe_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: concern_assessment
+
+  - id: procedure_anxiety_severe_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: procedure_anxiety_severe_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/procedure_anxiety_severe/triggers.yaml b/list/taxonomy/procedure_anxiety_severe/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c178c568fda9cc68821fa337d747e6d68353a85a
--- /dev/null
+++ b/list/taxonomy/procedure_anxiety_severe/triggers.yaml
@@ -0,0 +1,77 @@
+domain: procedure_anxiety_severe
+priority: 40
+
+lexical_signals:
+  high:
+    phrases:
+      - "can't go through with this"
+      - "too scared for surgery"
+      - "want to cancel my surgery"
+      - "having a panic attack about the procedure"
+      - "don't think I can do this"
+      - "can't do the surgery"
+      - "need to cancel the operation"
+      - "too anxious to go through with it"
+      - "having second thoughts about surgery"
+      - "terrified of going under"
+      - "can't stop thinking about dying during surgery"
+      - "want to back out of the procedure"
+      - "too frightened to have the operation"
+      - "I am not going through with this surgery"
+      - "please cancel my procedure"
+      - "I refuse to have the surgery"
+      - "panicking about anesthesia"
+    regex:
+      - "(can't|cannot|don't\\s+think\\s+I\\s+can|unable\\s+to|refuse\\s+to).{0,15}(go\\s+through|do|have|handle).{0,10}(surgery|procedure|operation)"
+      - "(cancel|back\\s+out|call\\s+off|postpone).{0,15}(surgery|procedure|operation)"
+      - "(too|so|extremely|really).{0,10}(scared|frightened|terrified|anxious|panick).{0,15}(surgery|procedure|operation|anesthesia)"
+      - "(panic|panick|anxiety).{0,10}(attack|episode).{0,15}(surgery|procedure|operation)"
+      - "(terrified|petrified).{0,10}(of|about).{0,15}(surgery|procedure|operation|anesthesia|going\\s+under|dying)"
+  medium:
+    phrases:
+      - "nervous about surgery"
+      - "worried about the procedure"
+      - "anxious about going under"
+      - "scared about anesthesia"
+      - "dreading the surgery"
+      - "surgery makes me anxious"
+      - "worried about the operation"
+      - "stressed about the procedure"
+      - "can't sleep thinking about surgery"
+      - "really nervous about tomorrow"
+      - "anxiety about the anesthesia"
+      - "scared about what could go wrong"
+      - "worried something bad will happen"
+    regex:
+      - "(nervous|worried|anxious|scared|stressed|dread).{0,15}(about|for|of).{0,10}(surgery|procedure|operation|anesthesia|going\\s+under)"
+      - "(surgery|procedure|operation|anesthesia).{0,15}(makes?\\s+me|is\\s+making\\s+me).{0,10}(nervous|worried|anxious|scared)"
+      - "(can't|cannot)\\s+(sleep|relax|stop\\s+thinking).{0,15}(surgery|procedure|operation)"
+  low:
+    partials:
+      - "nervous"
+      - "worried about surgery"
+      - "scared"
+      - "anxious about procedure"
+      - "surgery anxiety"
+
+negation_handling:
+  patterns:
+    - "not too nervous"
+    - "handling it okay"
+    - "a little nervous but fine"
+    - "ready for surgery"
+    - "feeling prepared"
+    - "not worried about the surgery"
+    - "feeling confident"
+    - "looking forward to getting it done"
+    - "ready to go"
+    - "just a little nervous but that's normal"
+    - "managing my anxiety"
+    - "doing okay with it"
+    - "not too scared"
+    - "feeling okay about surgery"
+    - "prepared for the procedure"
+    - "not anxious"
+    - "calm about surgery"
+    - "at peace with it"
+  action: downgrade_confidence
diff --git a/list/taxonomy/progressive_weakness/flows/clarify.yaml b/list/taxonomy/progressive_weakness/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4360d99463f0a9351060db5f8655effbbc8d8d3d
--- /dev/null
+++ b/list/taxonomy/progressive_weakness/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: progressive_weakness
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: progressive_weakness_clarify
+      goal: "Ask patient to describe their progressive weakness symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - progressive_weakness_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/progressive_weakness/flows/escalate_r1.yaml b/list/taxonomy/progressive_weakness/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ab6b456be1eaface0c7875b73e04b32eafb17257
--- /dev/null
+++ b/list/taxonomy/progressive_weakness/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: progressive_weakness
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/progressive_weakness/flows/escalate_r2.yaml b/list/taxonomy/progressive_weakness/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3b40bdd0c073b82aec82ea4abad422c5e9aa8f60
--- /dev/null
+++ b/list/taxonomy/progressive_weakness/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: progressive_weakness
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: weakness_r2_escalation_notice
+      goal: "Inform patient that a nurse will follow up urgently about their weakness symptoms"
+      tone: calm_urgent
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "today"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: weakness_r2_handoff
+      goal: "Schedule same-day nurse callback for progressive weakness with red flag features"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/progressive_weakness/flows/escalate_r3.yaml b/list/taxonomy/progressive_weakness/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8f968f6d4cf14b3e4ad6dd95f3401978c6a6e039
--- /dev/null
+++ b/list/taxonomy/progressive_weakness/flows/escalate_r3.yaml
@@ -0,0 +1,27 @@
+flow_id: escalate_r3
+type: escalation
+domain: progressive_weakness
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: weakness_r3_escalation_notice
+    goal: Instruct patient to go to the emergency department immediately for progressive
+      weakness with breathing difficulty or bladder/bowel changes
+    tone: calm_urgent
+    must_include:
+    - call 911
+    - emergency
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably nothing
+    - wait
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+exit:
+  on_complete: end
diff --git a/list/taxonomy/progressive_weakness/flows/handoff.yaml b/list/taxonomy/progressive_weakness/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8aae6d049ed1a5c8ded0fab0d68b409a176d1f4d
--- /dev/null
+++ b/list/taxonomy/progressive_weakness/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: progressive_weakness
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: progressive_weakness_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: progressive_weakness_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/progressive_weakness/flows/safety_screen.yaml b/list/taxonomy/progressive_weakness/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..374fd7f17de55022127feb34852fddff07364831
--- /dev/null
+++ b/list/taxonomy/progressive_weakness/flows/safety_screen.yaml
@@ -0,0 +1,73 @@
+flow_id: safety_screen
+type: screening
+domain: progressive_weakness
+
+required_slots:
+  - ascending_weakness
+  - breathing_difficulty_new
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: weakness_screen_step1
+      goal: "Screen for ascending weakness pattern suggestive of Guillain-Barre syndrome"
+      tone: calm_urgent
+      must_include:
+        - "weakness"
+      must_ask:
+        - "Did the weakness start in your feet or legs and then move upward toward your upper body?"
+        - "Is the weakness on both sides of your body?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+        - "diagnos"
+      max_questions: 2
+    collects:
+      - ascending_weakness
+      - bilateral_weakness
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: weakness_screen_step2
+      goal: "Screen for bowel/bladder dysfunction suggestive of spinal cord compression"
+      tone: calm_urgent
+      must_include:
+        - "important"
+      must_ask:
+        - "Have you had any new problems with bladder control or bowel function?"
+        - "Are you having any new back pain along with the weakness?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - bowel_bladder_changes
+      - new_back_pain
+
+  - step: 3
+    type: ask
+    response_spec:
+      id: weakness_screen_step3
+      goal: "Screen for breathing difficulty and swallowing problems suggestive of myasthenic crisis or GBS respiratory involvement"
+      tone: calm_urgent
+      must_include:
+        - "breathing"
+      must_ask:
+        - "Are you having any new difficulty breathing or feeling short of breath?"
+        - "Are you having trouble swallowing or is your voice changing?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - breathing_difficulty_new
+      - swallowing_difficulty
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_r2: escalate_r2
+  on_low_risk: escalate_r1
+  on_unclear: escalate_r1
diff --git a/list/taxonomy/progressive_weakness/rules.yaml b/list/taxonomy/progressive_weakness/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..62e92e4cf7933cb62a6ce394a4a4fb51ebc945d2
--- /dev/null
+++ b/list/taxonomy/progressive_weakness/rules.yaml
@@ -0,0 +1,33 @@
+domain: progressive_weakness
+target_risk_class: R1
+
+decision_rules:
+  - id: progressive_weakness_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: progressive_weakness_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: progressive_weakness_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: progressive_weakness_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: progressive_weakness_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/progressive_weakness/triggers.yaml b/list/taxonomy/progressive_weakness/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..69793a01d3031d218e95a24fb06eef1b7968e1d4
--- /dev/null
+++ b/list/taxonomy/progressive_weakness/triggers.yaml
@@ -0,0 +1,56 @@
+domain: progressive_weakness
+priority: 36
+
+lexical_signals:
+  high:
+    phrases:
+      - "getting weaker every day"
+      - "progressive weakness"
+      - "can barely stand up now"
+      - "losing strength rapidly"
+      - "weakness getting worse each day"
+      - "fatigue worsening daily"
+      - "can't even get out of bed"
+      - "legs are giving out"
+      - "so weak I can't walk"
+      - "my strength is declining"
+      - "weaker and weaker"
+      - "muscles are getting weaker"
+      - "can barely move"
+      - "too weak to do anything"
+    regex:
+      - "(progressive|getting\\s+worse|worsening)\\s+(weakness|fatigue)"
+      - "weaker\\s+every\\s+day"
+      - "(can'?t|can\\s+barely|unable\\s+to)\\s+(stand|walk|get\\s+(up|out))"
+      - "weak(er|ness)?\\s+(and\\s+weak|getting|is\\s+(worse|getting))"
+      - "(too|so)\\s+weak"
+  medium:
+    phrases:
+      - "feeling weaker than before"
+      - "less strength than last week"
+      - "getting more fatigued"
+      - "weakness increasing"
+      - "not as strong as before discharge"
+      - "having trouble getting around"
+      - "my legs feel weak"
+      - "arms feel heavy"
+      - "exhausted all the time"
+      - "no energy at all"
+      - "feeling very weak"
+      - "more tired than usual"
+  low:
+    partials:
+      - "weakness"
+      - "fatigue"
+      - "weak"
+      - "losing strength"
+      - "no energy"
+      - "exhausted"
+      - "tired all the time"
+
+negation_handling:
+  patterns:
+    - "feeling stronger"
+    - "strength improving"
+    - "not weak anymore"
+  action: downgrade_confidence
diff --git a/list/taxonomy/psychiatric_med_crisis/flows/clarify.yaml b/list/taxonomy/psychiatric_med_crisis/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..2aa2c8fdc30af514f098ef8bbe354037c6a1f9e9
--- /dev/null
+++ b/list/taxonomy/psychiatric_med_crisis/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: psychiatric_med_crisis
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: psych_med_clarify
+      goal: "Gently ask patient to describe their medication situation"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "I want to make sure I understand. Could you tell me a bit more about your medication situation?"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - psych_med_clarify_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: escalate_r2
diff --git a/list/taxonomy/psychiatric_med_crisis/flows/escalate_r2.yaml b/list/taxonomy/psychiatric_med_crisis/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6f55672e8e84144df5fbf3ad610f4ed554d3ad8d
--- /dev/null
+++ b/list/taxonomy/psychiatric_med_crisis/flows/escalate_r2.yaml
@@ -0,0 +1,36 @@
+flow_id: escalate_r2
+type: escalation
+domain: psychiatric_med_crisis
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: psych_med_r2_escalation_notice
+      goal: "Connect patient with prescribing provider or psychiatric nurse for medication management"
+      tone: empathetic
+      must_include:
+        - "prescriber"
+        - "medication"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: psychiatric_nurse
+    urgency: same_day
+    response_spec:
+      id: psych_med_r2_handoff
+      goal: "Transfer to psychiatric nurse for medication management"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/psychiatric_med_crisis/flows/escalate_r3.yaml b/list/taxonomy/psychiatric_med_crisis/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..99ab3dec5bcefc1f60237f32437ff12471e6f317
--- /dev/null
+++ b/list/taxonomy/psychiatric_med_crisis/flows/escalate_r3.yaml
@@ -0,0 +1,38 @@
+flow_id: escalate_r3
+type: escalation
+domain: psychiatric_med_crisis
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: psych_med_r3_escalation_notice
+    goal: Life-threatening withdrawal (benzo/lithium/antipsychotic) — immediate medical
+      attention
+    tone: calm_urgent
+    must_include:
+    - call 911
+    - right away
+    - medical
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: psych_med_r3_handoff
+    goal: Transfer to clinical nurse for medical emergency
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/psychiatric_med_crisis/flows/safety_screen.yaml b/list/taxonomy/psychiatric_med_crisis/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..2ab66c0ee0e2d5b71fb74650d36312851bd63c24
--- /dev/null
+++ b/list/taxonomy/psychiatric_med_crisis/flows/safety_screen.yaml
@@ -0,0 +1,56 @@
+flow_id: safety_screen
+type: screening
+domain: psychiatric_med_crisis
+
+required_slots:
+  - med_discontinued
+  - discontinuation_reason
+  - withdrawal_symptoms
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: psych_med_screen_step1
+      goal: "Determine which medication was discontinued and why"
+      tone: gentle_professional
+      must_include:
+        - "understand"
+        - "help"
+      must_ask:
+        - "Which medication did you stop taking or run out of?"
+        - "What happened — did you run out, or did you decide to stop?"
+      must_not:
+        - "don't worry"
+        - "diagnos"
+        - "should have"
+      max_questions: 2
+    collects:
+      - med_discontinued
+      - discontinuation_reason
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: psych_med_screen_step2
+      goal: "Assess withdrawal symptoms and duration without medication"
+      tone: gentle_professional
+      must_include:
+        - "important"
+      must_ask:
+        - "What symptoms are you experiencing since stopping?"
+        - "How long has it been since your last dose?"
+      must_not:
+        - "don't worry"
+        - "diagnos"
+      max_questions: 2
+    collects:
+      - withdrawal_symptoms
+      - days_without_med
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_r2: escalate_r2
+  on_low_risk: escalate_r2
+  on_unclear: escalate_r2
diff --git a/list/taxonomy/psychiatric_med_crisis/rules.yaml b/list/taxonomy/psychiatric_med_crisis/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0b4a54735975c30005b7b8ff8f9c0c1a0610afde
--- /dev/null
+++ b/list/taxonomy/psychiatric_med_crisis/rules.yaml
@@ -0,0 +1,33 @@
+domain: psychiatric_med_crisis
+target_risk_class: R2
+
+decision_rules:
+  - id: psych_med_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: psych_med_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: psych_med_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: psych_med_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: psych_med_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/psychiatric_med_crisis/triggers.yaml b/list/taxonomy/psychiatric_med_crisis/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9f61400f72533b06f903e1d98c0c6156a0a0b461
--- /dev/null
+++ b/list/taxonomy/psychiatric_med_crisis/triggers.yaml
@@ -0,0 +1,90 @@
+domain: psychiatric_med_crisis
+priority: 65
+
+lexical_signals:
+  high:
+    phrases:
+      - "stopped my Xanax cold turkey"
+      - "brain zaps"
+      - "ran out of lithium and I'm shaking"
+      - "stopped my Klonopin cold turkey"
+      - "stopped my Ativan cold turkey"
+      - "quit my benzodiazepine"
+      - "ran out of lithium"
+      - "lithium toxicity"
+      - "stopped my antipsychotic and hearing voices"
+      - "electric shocks in my head"
+      - "stopped Seroquel cold turkey"
+      # --- NMS (neuroleptic malignant syndrome) ---
+      - "high fever and my muscles are rigid on antipsychotic"
+      - "high fever and stiff muscles after starting medication"
+      - "rigid muscles and very high fever"
+      - "confused with high fever and stiff muscles"
+      - "neuroleptic malignant syndrome"
+      - "NMS symptoms"
+      # --- Serotonin syndrome ---
+      - "serotonin syndrome"
+      - "tremor and sweating and fast heart on SSRI"
+      - "agitated and shaking and sweating on antidepressant"
+      - "jerking muscles and fever on antidepressant"
+      - "started new antidepressant and now shaking and sweating"
+    regex:
+      - "(stop|stopped|quit)\\s+(my\\s+)?(xanax|klonopin|ativan|valium|benzo|benzodiazepine|alprazolam|clonazepam|lorazepam|diazepam)\\s+(cold turkey|abrupt|sudden)"
+      - "(ran out|out of|can'?t get)\\s+(of\\s+)?(lithium|depakote|lamictal|seroquel|risperdal|zyprexa|abilify|clozapine)"
+      - "brain\\s+(zap|shock|jolt)"
+      - "(electric|zapping|shocking)\\s+(feeling|sensation)\\s+(in|through)\\s+(my\\s+)?(head|brain|body)"
+      - "(stop|stopped|quit).{0,20}(antipsychotic|mood stabilizer).{0,20}(hear|voice|hallucin|shak)"
+      # --- NMS patterns ---
+      - "(high\\s+fever|very\\s+high\\s+temperature).{0,25}(rigid|stiff)\\s+(muscle|body)"
+      - "(rigid|stiff)\\s+(muscle|body).{0,25}(fever|temperature)"
+      - "(neuroleptic\\s+malignant|NMS)"
+      - "(muscle\\s+rigidity|lead\\s+pipe\\s+rigidity).{0,20}(fever|temperature|confus|altered)"
+      - "(fever|temperature).{0,20}(confus|altered).{0,20}(antipsychotic|risperd|zyprex|haldol|seroquel|olanzap|quetiap|haloperidol)"
+      # --- Serotonin syndrome patterns ---
+      - "(serotonin\\s+syndrome)"
+      - "(tremor|shak|jerk|clonus|twitch).{0,20}(sweat|diaphores).{0,20}(antidepress|SSRI|SNRI)"
+      - "(agitat|restless).{0,20}(tremor|shak|jerk).{0,20}(sweat|diaphores|fever)"
+      - "(start|began|new).{0,15}(antidepress|SSRI|SNRI|sertraline|fluoxetine|paroxetine|venlafaxine|duloxetine|citalopram|escitalopram).{0,25}(tremor|shak|sweat|agitat|jerk|fever|confus)"
+      - "(tremor|clonus|myoclonus).{0,20}(fever|hypertherm).{0,20}(antidepress|SSRI|seroton)"
+  medium:
+    phrases:
+      - "stopped taking my psych meds"
+      - "can't afford my medication"
+      - "pharmacy won't fill"
+      - "ran out of my antidepressant"
+      - "stopped my SSRI"
+      - "can't get my prescription"
+      - "insurance won't cover my medication"
+      - "missed my lithium for days"
+      - "haven't taken my psych meds in a week"
+      - "stopped my medication without telling my doctor"
+      - "doctor took me off my meds suddenly"
+      - "feeling awful since stopping my medication"
+      - "dizzy since I stopped my antidepressant"
+    regex:
+      - "(stop|stopped|quit|haven'?t taken|ran out|can'?t get|can'?t afford)\\s+(my\\s+)?(psych|psychiatric|mental health)\\s+(med|medication)"
+      - "(stop|stopped|quit|missed|haven'?t taken).{0,20}(antidepressant|SSRI|SNRI|mood stabilizer|antipsychotic|lithium|lamotrigine|valproate|quetiapine|risperidone|olanzapine|aripiprazole|clozapine)"
+      - "(pharmacy|insurance|prescription).{0,20}(won'?t|can'?t|denied|refused|not cover)"
+      - "(feel|feeling).{0,15}(awful|terrible|horrible|sick|worse).{0,20}(stop|quit|ran out|without|missing)"
+  low:
+    partials:
+      - "stopped medication"
+      - "ran out of meds"
+      - "can't get my medication"
+      - "medication discontinued"
+      - "off my meds"
+      - "not taking my meds"
+
+negation_handling:
+  patterns:
+    - "taking medication as prescribed"
+    - "just changed dose with doctor"
+    - "doctor adjusted my medication"
+    - "tapered off with doctor"
+    - "gradually reduced"
+    - "switched medications with my doctor"
+    - "medication is working well"
+    - "picking up my prescription"
+    - "got my refill"
+    - "pharmacy filled it"
+  action: downgrade_confidence
diff --git a/list/taxonomy/recurrent_falls/flows/clarify.yaml b/list/taxonomy/recurrent_falls/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7fe9adf8eb3bd093dd1775b11425f303ff3352b6
--- /dev/null
+++ b/list/taxonomy/recurrent_falls/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: recurrent_falls
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: recurrent_falls_clarify
+      goal: "Ask patient to describe their recurrent falls symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - recurrent_falls_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/recurrent_falls/flows/escalate_r1.yaml b/list/taxonomy/recurrent_falls/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8e0130dafe22a1d5bc4da9042a4a2d0365c84671
--- /dev/null
+++ b/list/taxonomy/recurrent_falls/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: recurrent_falls
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/recurrent_falls/flows/handoff.yaml b/list/taxonomy/recurrent_falls/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..231262914df049de925c57485acbbe2b8b36217b
--- /dev/null
+++ b/list/taxonomy/recurrent_falls/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: recurrent_falls
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: recurrent_falls_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: recurrent_falls_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/recurrent_falls/rules.yaml b/list/taxonomy/recurrent_falls/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a8ffed8e1bb648b8fc15b6feda1b9e12cd368de3
--- /dev/null
+++ b/list/taxonomy/recurrent_falls/rules.yaml
@@ -0,0 +1,21 @@
+domain: recurrent_falls
+target_risk_class: R1
+
+decision_rules:
+  - id: recurrent_falls_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r1
+
+  - id: recurrent_falls_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r1
+
+  - id: recurrent_falls_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/recurrent_falls/triggers.yaml b/list/taxonomy/recurrent_falls/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..dfb4589773666ba4b6d6c7b4bf715e5dc984268e
--- /dev/null
+++ b/list/taxonomy/recurrent_falls/triggers.yaml
@@ -0,0 +1,54 @@
+domain: recurrent_falls
+priority: 45
+
+lexical_signals:
+  high:
+    phrases:
+      - "keep falling"
+      - "fell again today"
+      - "third fall this week"
+      - "recurrent falls"
+      - "falling frequently"
+      - "keep losing my balance and falling"
+      - "I fell down again"
+      - "fell twice this week"
+      - "fallen multiple times"
+      - "keep tripping and falling"
+      - "I fall every day"
+      - "can't stop falling"
+      - "another fall last night"
+      - "falling at home"
+    regex:
+      - "(keep|recurrent|frequent|multiple|repeated)\\s+fall"
+      - "fell\\s+(again|down|twice|three|multiple)"
+      - "fall(ing|en|s)?\\s+(every|all|at\\s+home|frequently|multiple|more)"
+      - "(keep|can'?t\\s+stop)\\s+(fall|trip)"
+  medium:
+    phrases:
+      - "fell a couple times this week"
+      - "another fall today"
+      - "falling more often"
+      - "unsteady and falling"
+      - "had another fall recently"
+      - "I fell yesterday"
+      - "almost fell a few times"
+      - "my balance is terrible"
+      - "tripping over things"
+      - "stumbling a lot"
+      - "I keep stumbling"
+  low:
+    partials:
+      - "falls"
+      - "falling"
+      - "unsteady"
+      - "balance problems"
+      - "stumbling"
+      - "tripping"
+      - "fell down"
+
+negation_handling:
+  patterns:
+    - "no falls"
+    - "steady on my feet"
+    - "balance is good"
+  action: downgrade_confidence
diff --git a/list/taxonomy/reproducible_chest_discomfort/flows/clarify.yaml b/list/taxonomy/reproducible_chest_discomfort/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0df74a1baecad8254cebc076890e014be6613580
--- /dev/null
+++ b/list/taxonomy/reproducible_chest_discomfort/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: reproducible_chest_discomfort
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: reproducible_chest_discomfort_clarify
+      goal: "Ask patient to describe their reproducible chest discomfort symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - reproducible_chest_discomfort_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/reproducible_chest_discomfort/flows/escalate_r1.yaml b/list/taxonomy/reproducible_chest_discomfort/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..23ac5372d2364883bb108750fab7942aea2cdb0f
--- /dev/null
+++ b/list/taxonomy/reproducible_chest_discomfort/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: reproducible_chest_discomfort
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/reproducible_chest_discomfort/flows/handoff.yaml b/list/taxonomy/reproducible_chest_discomfort/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a3964223dce8f85b279b283230e880f4de9eea63
--- /dev/null
+++ b/list/taxonomy/reproducible_chest_discomfort/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: reproducible_chest_discomfort
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: reproducible_chest_discomfort_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: reproducible_chest_discomfort_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/reproducible_chest_discomfort/rules.yaml b/list/taxonomy/reproducible_chest_discomfort/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e86f41dbac4bf79bee8d1abb7d604e76af882724
--- /dev/null
+++ b/list/taxonomy/reproducible_chest_discomfort/rules.yaml
@@ -0,0 +1,21 @@
+domain: reproducible_chest_discomfort
+target_risk_class: R1
+
+decision_rules:
+  - id: reproducible_chest_discomfort_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r1
+
+  - id: reproducible_chest_discomfort_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r1
+
+  - id: reproducible_chest_discomfort_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/reproducible_chest_discomfort/triggers.yaml b/list/taxonomy/reproducible_chest_discomfort/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..12e5997189266d2df7d97c8d6b8a765a83fa8fcc
--- /dev/null
+++ b/list/taxonomy/reproducible_chest_discomfort/triggers.yaml
@@ -0,0 +1,154 @@
+domain: reproducible_chest_discomfort
+priority: 38
+
+lexical_signals:
+  high:
+    phrases:
+      - "chest hurts when I press on it"
+      - "chest pain only when I move a certain way"
+      - "reproducible chest pain"
+      - "chest pain is positional"
+      - "chest discomfort when I twist or turn"
+      - "chest wall tenderness when pressing"
+      - "pain in my chest when I push on it"
+      - "if I press right here on my chest it hurts"
+      - "I can make the chest pain happen by moving"
+      - "chest pain goes away when I stop moving"
+      - "hurts only when I reach overhead"
+      - "chest pain when I take a deep breath and twist"
+      - "sore spot on my chest wall"
+      - "tender spot on my sternum when I press"
+      - "chest pain that I can reproduce every time"
+      - "it only hurts when I push on that exact spot"
+      - "my chest is sore to the touch"
+      - "the pain comes back every time I lift something"
+      - "chest pain when I bend forward"
+      - "I can point to the exact spot that hurts"
+      - "hurts right here when I press"
+      - "musculoskeletal chest pain"
+      - "costochondritis"
+      - "chest wall pain when I cough"
+      - "sharp chest pain when I twist my torso"
+      - "tender right on the breastbone"
+      - "it hurts in my chest only when I push on that rib"
+      - "chest pain that comes and goes with arm movement"
+    regex:
+      - "chest.*(press|position|reproduc|movement|twist)"
+      - "chest\\s+wall\\s+tender"
+      - "chest.*(hurts?|pain|sore).*(press|push|touch|poke)"
+      - "(press|push|touch|poke).*(chest|sternum|rib).*(hurts?|pain|sore|tender)"
+      - "chest.*(pain|hurts?|sore).*(move|twist|turn|bend|reach|lift|stretch)"
+      - "(move|twist|turn|bend|reach|lift|stretch).*(chest|sternum).*(hurts?|pain|sore)"
+      - "chest.*(pain|hurts?).*every\\s+time\\s+I"
+      - "can\\s+make.*(chest|pain).*happen"
+      - "point\\s+to.*(exact|specific)\\s+spot"
+      - "sore\\s+spot.*(chest|sternum|rib)"
+      - "costochondritis"
+      - "chest\\s+wall\\s+(pain|sore|tender|discomfort)"
+      - "(one|specific|exact|certain)\\s+spot.*(chest|sternum|rib)"
+      - "chest.*(pain|hurts?).*(arm|shoulder)\\s+(move|motion|reach)"
+      - "tender.*(right|directly)\\s+on.*(sternum|breastbone|rib)"
+  medium:
+    phrases:
+      - "chest pain comes with certain movement"
+      - "discomfort in chest when pressing"
+      - "chest wall tenderness"
+      - "musculoskeletal chest pain"
+      - "chest pain with certain positions only"
+      - "my chest has been sore"
+      - "chest feels bruised"
+      - "feels like a pulled muscle in my chest"
+      - "it hurts when I sneeze or cough in my chest"
+      - "my ribs are sore"
+      - "pain between my ribs"
+      - "sharp pain when I take a deep breath"
+      - "chest pain worse when I lie on that side"
+      - "it comes and goes with how I move"
+      - "chest pain for a few days but only with movement"
+      - "I think I pulled something in my chest"
+      - "the spot is tender if I rub it"
+      - "hurts when I stretch"
+      - "pain right along my breastbone"
+      - "intercostal pain"
+      - "my chest hurts after working out"
+      - "sore right where my ribs connect"
+      - "it feels muscular not like a heart thing"
+      - "pain is on the surface not deep"
+      - "worse when I take a big breath"
+      - "chest is achy when I roll over in bed"
+      - "hurts more when I carry something heavy"
+      - "my chest has been sore since I moved furniture"
+      - "feels like something is strained in my chest"
+      - "chest tightness only in certain positions"
+      - "sore along the cartilage near my ribs"
+      - "pain flares up when I use my arm on that side"
+    regex:
+      - "chest.*(bruise|pull|strain|muscle|sore)"
+      - "(pull|strain|muscle).*(chest|rib|sternum)"
+      - "chest.*(sneeze|cough|laugh|yawn).*(hurts?|pain|worse)"
+      - "(sneeze|cough|laugh|yawn).*(chest|rib).*(hurts?|pain|worse)"
+      - "chest.*(comes?\\s+and\\s+go|off\\s+and\\s+on|intermittent).*mov"
+      - "(rib|ribs|sternum|breastbone).*(sore|tender|pain|hurts?)"
+      - "deep\\s+breath.*(chest|rib).*(hurts?|pain|sharp)"
+      - "chest.*(deep\\s+breath|breath).*(hurts?|pain|sharp|worse)"
+      - "chest.*(surface|superficial|muscular|not\\s+deep)"
+      - "(work|exercise|lift|gym).*(chest|rib).*(sore|pain|hurts?)"
+      - "chest.*(work|exercise|lift|gym).*(sore|pain|hurts?)"
+      - "intercostal"
+      - "chest.*(achy|ache|sore).*(roll|lie|lay|sleep|bed|side)"
+      - "(carry|haul|lift|move).*(heavy|furniture|box).*(chest|rib).*(sore|pain|hurts?)"
+      - "chest.*(strained|strain|tight).*(position|certain|only)"
+      - "cartilage.*(rib|chest).*(sore|tender|pain)"
+      - "(flare|worse|hurts?\\s+more).*(arm|shoulder).*(that|same)\\s+side"
+  low:
+    partials:
+      - "chest tender"
+      - "positional chest"
+      - "reproducible chest"
+      - "chest sore"
+      - "rib pain"
+      - "chest bruised"
+      - "chest pulled"
+      - "sternum sore"
+      - "breastbone pain"
+      - "chest movement"
+      - "chest when I press"
+      - "chest when I move"
+      - "sharp chest"
+      - "sore ribs"
+      - "chest wall"
+      - "surface pain chest"
+      - "muscular chest pain"
+      - "chest strain"
+      - "chest cartilage"
+      - "rib cartilage"
+      - "chest achy"
+      - "chest tight position"
+
+negation_handling:
+  patterns:
+    - "chest doesn't hurt with movement"
+    - "no chest tenderness"
+    - "chest pain gone"
+    - "chest pain not related to movement"
+    - "pressing on chest doesn't hurt"
+    - "no tenderness to palpation"
+    - "no reproducible pain"
+    - "chest is not sore anymore"
+    - "chest wall not tender"
+    - "no pain when I press on it"
+    - "the soreness went away"
+    - "no musculoskeletal component"
+    - "not positional"
+    - "pain doesn't change with movement"
+    - "not affected by position"
+    - "not tender to touch"
+    - "no chest wall tenderness"
+    - "chest feels fine now"
+    - "pain resolved completely"
+    - "no longer sore"
+    - "ribs are not tender"
+    - "costochondritis resolved"
+    - "chest strain healed"
+    - "no pain with deep breathing"
+  action: downgrade_confidence
diff --git a/list/taxonomy/scheduling/flows/cancel.yaml b/list/taxonomy/scheduling/flows/cancel.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0aa61153b62e638ad543b176f78aa682d7e973e8
--- /dev/null
+++ b/list/taxonomy/scheduling/flows/cancel.yaml
@@ -0,0 +1,27 @@
+flow_id: cancel
+type: service
+domain: scheduling
+
+required_slots:
+  - existing_appointment
+  - cancel_reason
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: cancel_gather
+      goal: "Confirm which appointment to cancel and reason"
+      tone: helpful_professional
+      must_include:
+        - "cancel"
+      must_ask:
+        - "which appointment"
+      must_not: []
+      max_questions: 2
+    collects:
+      - existing_appointment
+      - cancel_reason
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/scheduling/flows/clarify.yaml b/list/taxonomy/scheduling/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..41bbd32fc20571409c361ae61652df043447b11b
--- /dev/null
+++ b/list/taxonomy/scheduling/flows/clarify.yaml
@@ -0,0 +1,23 @@
+flow_id: clarify
+type: clarification
+domain: scheduling
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: scheduling_clarify
+      goal: "Ask patient to clarify their scheduling need"
+      tone: gentle_professional
+      must_include:
+        - "appointment"
+      must_ask:
+        - "help me understand"
+      must_not: []
+      max_questions: 2
+    collects:
+      - scheduling_intent
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/scheduling/flows/new_appt.yaml b/list/taxonomy/scheduling/flows/new_appt.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..495aaf46bd1025b8f6472d0567bca703bca96eb4
--- /dev/null
+++ b/list/taxonomy/scheduling/flows/new_appt.yaml
@@ -0,0 +1,32 @@
+flow_id: new_appt
+type: service
+domain: scheduling
+
+required_slots:
+  - preferred_date
+  - preferred_time
+  - provider_preference
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: schedule_gather
+      goal: "Gather appointment preferences from patient"
+      tone: helpful_professional
+      must_include:
+        - "appointment"
+      must_ask:
+        - "when would you like"
+        - "provider"
+      must_not:
+        - "diagnos"
+      max_questions: 2
+    collects:
+      - preferred_date
+      - preferred_time
+      - provider_preference
+
+exit:
+  on_complete: end
+  on_unclear: clarify
diff --git a/list/taxonomy/scheduling/flows/reschedule.yaml b/list/taxonomy/scheduling/flows/reschedule.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..09d906f232f6b5cc18acfd21da61a5c1db8a3baa
--- /dev/null
+++ b/list/taxonomy/scheduling/flows/reschedule.yaml
@@ -0,0 +1,28 @@
+flow_id: reschedule
+type: service
+domain: scheduling
+
+required_slots:
+  - existing_appointment
+  - new_preferred_date
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: reschedule_gather
+      goal: "Confirm existing appointment and gather new preferred time"
+      tone: helpful_professional
+      must_include:
+        - "reschedule"
+      must_ask:
+        - "current appointment"
+        - "new date"
+      must_not: []
+      max_questions: 2
+    collects:
+      - existing_appointment
+      - new_preferred_date
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/scheduling/rules.yaml b/list/taxonomy/scheduling/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d7014330ccab29c8775115f7f5ce7551da13f2f7
--- /dev/null
+++ b/list/taxonomy/scheduling/rules.yaml
@@ -0,0 +1,30 @@
+domain: scheduling
+
+decision_rules:
+  - id: scheduling_new_appt
+    if:
+      confidence: high
+    then:
+      flow: new_appt
+
+  - id: scheduling_reschedule
+    if:
+      confidence: medium
+      slots_present:
+        - existing_appointment
+    then:
+      flow: reschedule
+
+  - id: scheduling_cancel
+    if:
+      confidence: medium
+      slots_present:
+        - cancel_request
+    then:
+      flow: cancel
+
+  - id: scheduling_low
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/scheduling/triggers.yaml b/list/taxonomy/scheduling/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d40debee3f7fd7a0fde7220de4cf70ab42bac26a
--- /dev/null
+++ b/list/taxonomy/scheduling/triggers.yaml
@@ -0,0 +1,33 @@
+domain: scheduling
+priority: 30
+
+lexical_signals:
+  high:
+    phrases:
+      - "schedule an appointment"
+      - "book an appointment"
+      - "need to see the doctor"
+      - "reschedule"
+      - "cancel my appointment"
+    regex:
+      - "(schedule|book|make)\\s+(an?\\s+)?appointment"
+  medium:
+    phrases:
+      - "when can I come in"
+      - "next available"
+      - "follow up visit"
+    partials:
+      - "appointment"
+      - "schedule"
+  low:
+    phrases:
+      - "need to come in"
+    partials:
+      - "visit"
+      - "office"
+
+negation_handling:
+  patterns:
+    - "don't need an appointment"
+    - "no appointment needed"
+  action: suppress
diff --git a/list/taxonomy/scheduling_barrier/flows/barrier_assessment.yaml b/list/taxonomy/scheduling_barrier/flows/barrier_assessment.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..628ec1a938d0384c27bc2ee2dfdadefb89d4debb
--- /dev/null
+++ b/list/taxonomy/scheduling_barrier/flows/barrier_assessment.yaml
@@ -0,0 +1,52 @@
+flow_id: barrier_assessment
+type: assessment
+domain: scheduling_barrier
+
+required_slots:
+  - barrier_type
+  - resource_need
+  - preferred_appointment_time
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: scheduling_barrier_assess_step1
+      goal: "Identify the specific barrier preventing the patient from completing their care"
+      tone: warm_empathetic
+      must_include:
+        - "understand"
+        - "help"
+      must_ask:
+        - "Can you tell me more about what's making it hard to get to your appointment?"
+        - "Is this related to transportation, cost, work schedule, or something else?"
+      must_not:
+        - "you need to figure this out"
+        - "that's not our problem"
+      max_questions: 2
+    collects:
+      - barrier_type
+      - resource_need
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: scheduling_barrier_assess_step2
+      goal: "Understand scheduling preferences and explore what would help the patient access care"
+      tone: warm_empathetic
+      must_include:
+        - "options"
+      must_ask:
+        - "What time or day would work best for you if we could help arrange something?"
+      must_not:
+        - "you have to"
+        - "no excuse"
+      max_questions: 1
+    collects:
+      - preferred_appointment_time
+
+exit:
+  on_complete: evaluate_concern
+  on_concern: resource_referral
+  on_low_risk: scheduling_assist
+  on_unclear: resource_referral
diff --git a/list/taxonomy/scheduling_barrier/flows/clarify.yaml b/list/taxonomy/scheduling_barrier/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9af0164a47c986b3c15d900d721318aba04b91f7
--- /dev/null
+++ b/list/taxonomy/scheduling_barrier/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: scheduling_barrier
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: scheduling_barrier_clarify
+      goal: "Ask the patient to clarify what barrier they are experiencing with their care"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "Could you tell me a bit more about what's making it hard to complete your care?"
+      must_not:
+        - "you need to"
+        - "you must"
+      max_questions: 1
+    collects:
+      - scheduling_barrier_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: resource_referral
diff --git a/list/taxonomy/scheduling_barrier/flows/resource_referral.yaml b/list/taxonomy/scheduling_barrier/flows/resource_referral.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f43395eba98d17ab5b840f152363d26b63050111
--- /dev/null
+++ b/list/taxonomy/scheduling_barrier/flows/resource_referral.yaml
@@ -0,0 +1,21 @@
+flow_id: resource_referral
+type: resolution
+domain: scheduling_barrier
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: scheduling_barrier_resource_referral
+      goal: "Connect the patient with appropriate resources for their identified barrier and document the need"
+      tone: warm_professional
+      must_include:
+        - "resources"
+        - "care team"
+      must_not:
+        - "nothing we can do"
+        - "your problem"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/scheduling_barrier/flows/scheduling_assist.yaml b/list/taxonomy/scheduling_barrier/flows/scheduling_assist.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9045aff2de6c00d4b0c8aecbd8275b927ea15c9c
--- /dev/null
+++ b/list/taxonomy/scheduling_barrier/flows/scheduling_assist.yaml
@@ -0,0 +1,21 @@
+flow_id: scheduling_assist
+type: resolution
+domain: scheduling_barrier
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: scheduling_barrier_scheduling_assist
+      goal: "Help the patient identify a workable time and note their preferences for the care team to follow up on scheduling"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "nothing we can do"
+        - "that's not possible"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/scheduling_barrier/rules.yaml b/list/taxonomy/scheduling_barrier/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..956c269676d5de90d140e11712dfde74b77332e5
--- /dev/null
+++ b/list/taxonomy/scheduling_barrier/rules.yaml
@@ -0,0 +1,21 @@
+domain: scheduling_barrier
+target_risk_class: R0
+
+decision_rules:
+  - id: scheduling_barrier_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: barrier_assessment
+
+  - id: scheduling_barrier_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: barrier_assessment
+
+  - id: scheduling_barrier_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/scheduling_barrier/triggers.yaml b/list/taxonomy/scheduling_barrier/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4be164a62f8201d461efec343749f678b28bf3d0
--- /dev/null
+++ b/list/taxonomy/scheduling_barrier/triggers.yaml
@@ -0,0 +1,81 @@
+domain: scheduling_barrier
+priority: 31
+
+lexical_signals:
+  high:
+    phrases:
+      - "can't get there"
+      - "too expensive"
+      - "no ride to the appointment"
+      - "can't take time off work"
+      - "no insurance for that"
+      - "can't afford the copay"
+      - "don't have transportation"
+      - "no way to get to the doctor"
+      - "can't afford the test"
+      - "don't have a car"
+      - "no one to drive me"
+      - "can't miss work for the appointment"
+      - "insurance won't cover it"
+      - "cost is too much"
+      - "can't pay for the visit"
+      - "no bus route to the clinic"
+      - "too far to travel"
+      - "can't get a ride"
+    regex:
+      - "(can't|cannot|unable|no\\s+way).{0,15}(get\\s+there|get\\s+to|make\\s+it|afford|pay)"
+      - "(no|don't\\s+have).{0,15}(ride|transport|car|driver|insurance|money|way\\s+to\\s+get)"
+      - "(too|really).{0,10}(expensive|costly|far|much\\s+money)"
+      - "(can't|cannot).{0,15}(take\\s+time\\s+off|miss\\s+work|leave\\s+work|get\\s+off\\s+work)"
+      - "(insurance|coverage).{0,15}(won't|doesn't|does\\s+not|don't).{0,10}(cover|pay|include)"
+      - "(cost|copay|deductible|bill).{0,10}(too\\s+much|too\\s+high|too\\s+expensive|can't\\s+afford)"
+  medium:
+    phrases:
+      - "transportation issue"
+      - "worried about the cost"
+      - "not sure I can get there"
+      - "schedule conflict"
+      - "hard to get to appointments"
+      - "financial concern about the visit"
+      - "need help with transportation"
+      - "looking for a ride"
+      - "the visit is expensive"
+      - "struggling to afford care"
+      - "work schedule is a problem"
+    partials:
+      - "transportation"
+      - "can't afford"
+      - "no ride"
+      - "too expensive"
+      - "no insurance"
+      - "cost of the"
+      - "can't get there"
+      - "time off work"
+  low:
+    partials:
+      - "cost"
+      - "afford"
+      - "ride"
+      - "transportation"
+      - "insurance"
+      - "too far"
+      - "work schedule"
+
+negation_handling:
+  patterns:
+    - "I can get there"
+    - "I have a ride"
+    - "transportation is not a problem"
+    - "I can afford it"
+    - "insurance covers it"
+    - "cost is fine"
+    - "no trouble getting there"
+    - "I have a way to get there"
+    - "I can take time off"
+    - "my insurance will cover it"
+    - "not worried about cost"
+    - "rides are not an issue"
+    - "getting there is easy"
+    - "I have transportation"
+    - "I can make it"
+  action: downgrade_confidence
diff --git a/list/taxonomy/screening_gap_identified/flows/clarify.yaml b/list/taxonomy/screening_gap_identified/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c19b13f022454c9deff171ba8c5a49f3059e032b
--- /dev/null
+++ b/list/taxonomy/screening_gap_identified/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: screening_gap_identified
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: screening_gap_clarify
+      goal: "Ask patient to describe which screening or preventive care they are asking about"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "cancer"
+      max_questions: 1
+    collects:
+      - screening_gap_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: gap_notification
diff --git a/list/taxonomy/screening_gap_identified/flows/gap_notification.yaml b/list/taxonomy/screening_gap_identified/flows/gap_notification.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..381b0339e998e4591ad7cc39d28113badbfea8b6
--- /dev/null
+++ b/list/taxonomy/screening_gap_identified/flows/gap_notification.yaml
@@ -0,0 +1,52 @@
+flow_id: gap_notification
+type: assessment
+domain: screening_gap_identified
+
+required_slots:
+  - gap_type
+  - last_screening_date
+  - scheduling_preference
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: screening_gap_notify_step1
+      goal: "Identify which screening is overdue and when the patient last had it"
+      tone: supportive_professional
+      must_include:
+        - "important"
+        - "screening"
+      must_ask:
+        - "Which screening are we talking about?"
+        - "Do you remember approximately when you last had this done?"
+      must_not:
+        - "cancer"
+        - "too late"
+        - "dangerous"
+      max_questions: 2
+    collects:
+      - gap_type
+      - last_screening_date
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: screening_gap_notify_step2
+      goal: "Help the patient plan to schedule the screening"
+      tone: supportive_professional
+      must_include:
+        - "schedule"
+      must_ask:
+        - "Would you like help scheduling this screening?"
+      must_not:
+        - "cancer"
+        - "overdue"
+        - "negligent"
+      max_questions: 1
+    collects:
+      - scheduling_preference
+
+exit:
+  on_complete: scheduling_assist
+  on_unclear: scheduling_assist
diff --git a/list/taxonomy/screening_gap_identified/flows/scheduling_assist.yaml b/list/taxonomy/screening_gap_identified/flows/scheduling_assist.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d469e2d3bc56ec16bdcb12b764e8a945a1daa5fc
--- /dev/null
+++ b/list/taxonomy/screening_gap_identified/flows/scheduling_assist.yaml
@@ -0,0 +1,22 @@
+flow_id: scheduling_assist
+type: resolution
+domain: screening_gap_identified
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: screening_gap_schedule_assist
+      goal: "Confirm the screening gap has been noted and inform the patient their care team will help schedule it"
+      tone: supportive_professional
+      must_include:
+        - "care team"
+        - "schedule"
+      must_not:
+        - "cancer"
+        - "too late"
+        - "dangerous"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/screening_gap_identified/rules.yaml b/list/taxonomy/screening_gap_identified/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..703db1ef4efae1d6deba04fe64f8376007baef35
--- /dev/null
+++ b/list/taxonomy/screening_gap_identified/rules.yaml
@@ -0,0 +1,21 @@
+domain: screening_gap_identified
+target_risk_class: R0
+
+decision_rules:
+  - id: screening_gap_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: gap_notification
+
+  - id: screening_gap_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: gap_notification
+
+  - id: screening_gap_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/screening_gap_identified/triggers.yaml b/list/taxonomy/screening_gap_identified/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..25456b70d8187a0edc687c7a3ba1607b6da412d1
--- /dev/null
+++ b/list/taxonomy/screening_gap_identified/triggers.yaml
@@ -0,0 +1,64 @@
+domain: screening_gap_identified
+priority: 20
+
+lexical_signals:
+  high:
+    phrases:
+      - "overdue for my mammogram"
+      - "haven't had a colonoscopy in years"
+      - "overdue for my screening"
+      - "missed my cancer screening"
+      - "need to schedule my mammogram"
+      - "haven't had my annual screening"
+      - "overdue for a pap smear"
+      - "way past due for colonoscopy"
+      - "skipped my screening last year"
+      - "haven't had a bone density test"
+      - "need to get my colon checked"
+      - "behind on my screenings"
+      - "overdue for my physical"
+    regex:
+      - "(overdue|past\\s+due|behind|late).{0,15}(screening|mammogram|colonoscopy|pap|physical|check.?up)"
+      - "(haven't|have\\s+not|didn't|never).{0,15}(had|done|gotten|scheduled).{0,15}(screening|mammogram|colonoscopy|pap)"
+      - "(missed|skipped|forgot).{0,15}(screening|mammogram|colonoscopy|pap|check.?up|physical)"
+  medium:
+    phrases:
+      - "need to schedule a screening"
+      - "when was my last mammogram"
+      - "colonoscopy question"
+      - "screening reminder"
+      - "due for a check-up"
+      - "need to get screened"
+      - "should I get a mammogram"
+      - "time for my colonoscopy"
+      - "screening appointment"
+      - "preventive care"
+      - "need to schedule a physical"
+    partials:
+      - "mammogram"
+      - "colonoscopy"
+      - "screening"
+      - "pap smear"
+      - "bone density"
+      - "preventive"
+  low:
+    partials:
+      - "check-up"
+      - "overdue"
+      - "annual exam"
+      - "physical exam"
+
+negation_handling:
+  patterns:
+    - "up to date on screenings"
+    - "just had my mammogram"
+    - "colonoscopy was recent"
+    - "all screenings are current"
+    - "had my screening last month"
+    - "not overdue"
+    - "screenings are done"
+    - "everything is up to date"
+    - "just finished my screening"
+    - "already scheduled my mammogram"
+    - "already had my colonoscopy"
+  action: downgrade_confidence
diff --git a/list/taxonomy/screening_refusal/flows/acknowledge_refusal.yaml b/list/taxonomy/screening_refusal/flows/acknowledge_refusal.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5ff042774258f894664188fb2a4fbe9823255845
--- /dev/null
+++ b/list/taxonomy/screening_refusal/flows/acknowledge_refusal.yaml
@@ -0,0 +1,22 @@
+flow_id: acknowledge_refusal
+type: resolution
+domain: screening_refusal
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: screening_refusal_acknowledge
+      goal: "Respect the patient's decision, document the refusal, and let them know they can change their mind"
+      tone: warm_professional
+      must_include:
+        - "respect your decision"
+        - "care team"
+      must_not:
+        - "you should reconsider"
+        - "wrong choice"
+        - "irresponsible"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/screening_refusal/flows/clarify.yaml b/list/taxonomy/screening_refusal/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..dee33d99ef5a460a8dae9ce67a397a2b2f128763
--- /dev/null
+++ b/list/taxonomy/screening_refusal/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: screening_refusal
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: screening_refusal_clarify
+      goal: "Ask the patient to clarify whether they are declining a screening or test"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "Could you tell me a bit more about what you mean? Are you thinking about a particular test or screening?"
+      must_not:
+        - "you need to"
+        - "required"
+      max_questions: 1
+    collects:
+      - screening_refusal_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: acknowledge_refusal
diff --git a/list/taxonomy/screening_refusal/flows/motivational_support.yaml b/list/taxonomy/screening_refusal/flows/motivational_support.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c92043d0b9ecf9c51996234fed3476863bbb079c
--- /dev/null
+++ b/list/taxonomy/screening_refusal/flows/motivational_support.yaml
@@ -0,0 +1,54 @@
+flow_id: motivational_support
+type: assessment
+domain: screening_refusal
+
+required_slots:
+  - refusal_reason
+  - screening_type
+  - openness_to_discussion
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: screening_refusal_motivational_step1
+      goal: "Understand why the patient is declining the screening and which screening is involved"
+      tone: respectful_nonjudgmental
+      must_include:
+        - "understand"
+        - "respect"
+      must_ask:
+        - "Can you tell me a bit about why you'd prefer not to do this screening?"
+        - "Which screening or test are we talking about?"
+      must_not:
+        - "you should"
+        - "you have to"
+        - "wrong decision"
+      max_questions: 2
+    collects:
+      - refusal_reason
+      - screening_type
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: screening_refusal_motivational_step2
+      goal: "Explore whether the patient is open to discussing the screening further or receiving more information"
+      tone: respectful_nonjudgmental
+      must_include:
+        - "information"
+      must_ask:
+        - "Would you be open to hearing a little more about what the screening involves, or would you prefer we move on?"
+      must_not:
+        - "you need to"
+        - "you must"
+        - "irresponsible"
+      max_questions: 1
+    collects:
+      - openness_to_discussion
+
+exit:
+  on_complete: evaluate_concern
+  on_concern: acknowledge_refusal
+  on_low_risk: acknowledge_refusal
+  on_unclear: acknowledge_refusal
diff --git a/list/taxonomy/screening_refusal/rules.yaml b/list/taxonomy/screening_refusal/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5844895a8d15b9091dc571b0a6ee15243a9b8712
--- /dev/null
+++ b/list/taxonomy/screening_refusal/rules.yaml
@@ -0,0 +1,21 @@
+domain: screening_refusal
+target_risk_class: R0
+
+decision_rules:
+  - id: screening_refusal_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: motivational_support
+
+  - id: screening_refusal_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: motivational_support
+
+  - id: screening_refusal_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/screening_refusal/triggers.yaml b/list/taxonomy/screening_refusal/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..25bccd3b740d312ddfba3b6fba9e55584e0936b0
--- /dev/null
+++ b/list/taxonomy/screening_refusal/triggers.yaml
@@ -0,0 +1,70 @@
+domain: screening_refusal
+priority: 30
+
+lexical_signals:
+  high:
+    phrases:
+      - "don't want the test"
+      - "not interested in the screening"
+      - "refuse the screening"
+      - "I decline the test"
+      - "no thanks to the screening"
+      - "skip the test"
+      - "rather not do the screening"
+      - "don't believe in that test"
+      - "I'm not doing the screening"
+      - "I don't want to be screened"
+      - "not going to do the test"
+      - "I refuse"
+      - "count me out for the screening"
+      - "no screening for me"
+      - "I'll pass on the test"
+      - "don't want any tests"
+    regex:
+      - "(don't|do\\s+not|won't|will\\s+not|refuse|declining|decline)\\s+.{0,15}(test|screen|check|exam)"
+      - "(not\\s+interested|no\\s+thanks|skip|pass\\s+on|opt\\s+out).{0,15}(test|screen|check|exam)"
+      - "(don't|do\\s+not)\\s+believe\\s+in.{0,15}(test|screen|check|exam|mammo|colon)"
+      - "(rather|would\\s+rather)\\s+not.{0,15}(test|screen|check|exam|do\\s+it)"
+  medium:
+    phrases:
+      - "not sure about the test"
+      - "do I really need the screening"
+      - "I don't think I need it"
+      - "can I skip the screening"
+      - "is the test really necessary"
+      - "I heard the test isn't useful"
+      - "not comfortable with the test"
+      - "would rather wait on the screening"
+      - "don't see the point of the test"
+    partials:
+      - "refuse the test"
+      - "skip the screening"
+      - "not interested in screening"
+      - "decline the test"
+      - "opt out"
+      - "don't want screening"
+  low:
+    partials:
+      - "no thanks"
+      - "not interested"
+      - "rather not"
+      - "skip it"
+      - "don't believe in"
+
+negation_handling:
+  patterns:
+    - "I'll do the test"
+    - "go ahead with the screening"
+    - "okay I'll do it"
+    - "ready for the test"
+    - "I want the screening"
+    - "let's do the screening"
+    - "I agree to the test"
+    - "sign me up for the screening"
+    - "I changed my mind about refusing"
+    - "fine I'll do the test"
+    - "willing to do the screening"
+    - "yes to the test"
+    - "I consent to the screening"
+    - "okay let's go ahead"
+  action: downgrade_confidence
diff --git a/list/taxonomy/seizure/flows/clarify.yaml b/list/taxonomy/seizure/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..348c7fc3ffcb55f70370efe9f0f9043a8d9e38f3
--- /dev/null
+++ b/list/taxonomy/seizure/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: seizure
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: seizure_clarify
+      goal: "Ask patient to describe their seizure symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - seizure_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/seizure/flows/escalate_r3.yaml b/list/taxonomy/seizure/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8a56283ed48a7737efaa8a773b915e2d76f301fd
--- /dev/null
+++ b/list/taxonomy/seizure/flows/escalate_r3.yaml
@@ -0,0 +1,38 @@
+flow_id: escalate_r3
+type: escalation
+domain: seizure
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Inform patient this requires immediate clinical attention and they will
+      be transferred
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/seizure/flows/handoff.yaml b/list/taxonomy/seizure/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4478dd47279a7275b1b1aa145be4d71ead11a836
--- /dev/null
+++ b/list/taxonomy/seizure/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: seizure
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: seizure_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: seizure_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/seizure/rules.yaml b/list/taxonomy/seizure/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..aa7d2ecef680e1eb3ca91be44110d1ddc877db1d
--- /dev/null
+++ b/list/taxonomy/seizure/rules.yaml
@@ -0,0 +1,21 @@
+domain: seizure
+target_risk_class: R3
+
+decision_rules:
+  - id: seizure_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r3
+
+  - id: seizure_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r3
+
+  - id: seizure_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/seizure/triggers.yaml b/list/taxonomy/seizure/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c1a888a6b93644d5641b3c74717e5e51655ebd2b
--- /dev/null
+++ b/list/taxonomy/seizure/triggers.yaml
@@ -0,0 +1,275 @@
+domain: seizure
+priority: 90
+
+lexical_signals:
+  high:
+    phrases:
+      - "having a seizure"
+      - "convulsions"
+      - "seizure won't stop"
+      - "status epilepticus"
+      - "body shaking uncontrollably"
+      - "grand mal seizure"
+      - "seizing right now"
+      - "had a seizure"
+      - "just had a seizure"
+      - "started shaking on the"
+      - "went stiff and started shaking"
+      - "stiffened and started jerking"
+    regex:
+      - "(having|had|just had)\\s+a\\s+seizure"
+      - "status\\s+epilepticus"
+      - "(body|whole body).{0,10}(shak|jerk|convuls)"
+      - "seizure.{0,15}(just|right now|happened|earlier|today)"
+      - "(went|got|turned)\\s+stiff.{0,20}(shak|jerk|twitch|convuls)"
+      - "(stiffen|stiff).{0,15}(start|began|then).{0,10}(shak|jerk)"
+      - "started\\s+(shaking|jerking|convulsing|seizing)\\s+(on|in|at)"
+      - "(arms?|legs?|limbs?|body).{0,10}(were?|was|are|is)\\s+(jerking|shaking|twitching)"
+      - "stiff.{0,15}(then|and).{0,10}(jerk|shak|twitch)"
+      - "(staring|stared).{0,20}(stiff|rigid|jerk|shak|then)"
+  medium:
+    phrases:
+      - "started seizing"
+      - "seizure just happened"
+      - "body jerking"
+      - "convulsed earlier"
+      - "new seizure activity"
+      - "blanked out"
+      - "blacked out and fell"
+      - "on the floor and don't remember"
+      - "dropped to the ground"
+      - "fell and was shaking"
+      - "lost consciousness"
+      - "passed out and was shaking"
+      - "eyes rolled back"
+      - "think I had a seizure"
+      - "I think I had like a seizure"
+      - "tongue hurts"
+      - "missing a piece of time"
+      - "lost time"
+      - "blank spot"
+      - "wet myself"
+      - "staring then stiff then jerking"
+      - "staring first then stiff"
+      # --- from missed scenarios analysis ---
+      - "started shaking"
+      - "was shaking"
+      - "shaking real bad"
+      - "shaking really bad"
+      - "had some kind of fit"
+      - "had a fit"
+      - "had what I think was a seizure"
+      - "whole body was moving"
+      - "whole body was shaking"
+      - "wasn't responding"
+      - "wouldn't wake up"
+      # --- MINIMIZER coverage ---
+      - "had this weird episode"
+      - "body did this weird thing"
+      - "zoned out for a while"
+      - "lost a chunk of time"
+      - "don't remember the last few minutes"
+      - "tongue is sore and I don't know why"
+      # --- witness/caregiver report ---
+      - "another episode"
+      - "it happened again"
+      - "keeps happening"
+      - "they keep coming"
+      - "won't stop shaking"
+      - "still shaking"
+      - "found them on the floor shaking"
+      - "found him on the floor"
+      - "found her on the floor"
+      - "saw them shaking"
+      - "watched them collapse"
+      - "I saw him shaking"
+      - "I saw her shaking"
+      - "saw him collapse"
+      - "saw her collapse"
+      - "watched him shaking"
+      - "watched her shaking"
+      # --- post-ictal confusion ---
+      - "came to on the floor"
+      - "came to confused"
+      - "came to and felt confused"
+      - "woke up on the floor"
+      - "woke up confused"
+      - "doesn't remember what happened"
+      - "doesn't remember it"
+      - "doesn't remember anything"
+      - "doesn't remember the seizure"
+      - "don't remember what happened"
+      - "don't remember it happening"
+      # --- subtle seizure types / staring spells ---
+      - "staring spell"
+      - "staring spells"
+      - "just staring"
+      - "staring and not responding"
+      - "staring blankly"
+      - "blank stare"
+      - "staring and mumbling"
+      - "staring and making"
+      # --- aura descriptions ---
+      - "metallic taste"
+      - "burnt smell"
+      - "burnt toast smell"
+      - "weird smell before"
+      - "strange smell then"
+      - "deja vu then"
+      - "deja vu and"
+      - "rising feeling"
+      - "rising sensation"
+      - "weird rising sensation"
+      # --- first seizure / new seizure ---
+      - "first seizure"
+      - "first time seizure"
+      - "never had a seizure before"
+      - "new seizure"
+      - "like a seizure"
+      # --- duration concerns ---
+      - "keeps seizing"
+      - "seizures keep coming"
+      - "won't stop seizing"
+      - "multiple seizures"
+    regex:
+      - "(blank|black)ed\\s*(out)?"
+      - "(wet|peed|urinat|soiled).{0,15}(myself|self|pants|clothes)"
+      - "(fell|drop|collaps).{0,20}(floor|ground|down).{0,30}(shak|jerk|don't remember|no memory|can't remember)"
+      - "(shak|jerk|twitch).{0,20}(floor|ground|fell|drop)"
+      - "was\\s+on\\s+the\\s+floor"
+      - "then\\s+I\\s+was\\s+on\\s+the\\s+floor"
+      - "(eyes|eye)\\s+roll"
+      - "lost\\s+consciousness"
+      - "(bit|chew|hurt).{0,10}(tongue|cheek)"
+      - "missing.{0,10}(time|piece|chunk|gap|memory)"
+      - "lost\\s+time"
+      - "(blank|gap|hole)\\s+(spot|in my|in time)"
+      - "(shaking|jerking).{0,20}(on the|on his|on her|on their).{0,10}(floor|couch|ground|bed)"
+      - "(floor|ground).{0,20}(shaking|jerking|stiff|rigid)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(weird|strange).{0,10}(episode|spell|moment|thing).{0,15}(happened|had|earlier|today)"
+      - "(zoned|spaced|phased)\\s+out"
+      - "(don'?t|can'?t|couldn'?t)\\s+remember.{0,15}(how|what|getting|the last|anything|where|why)"
+      - "(shak|trembl|jerk|twitch).{0,20}(a bit|a little|kind of|slightly|for a (minute|moment|second))"
+      - "woke\\s+up.{0,15}(confused|don'?t know|didn'?t know|on the|somewhere)"
+      - "(gap|hole|blank|missing).{0,15}(in my|in time|memory|minutes|moment)"
+      - "body\\s+(did|does|doing).{0,10}(this|a|something).{0,10}(weird|strange|funny)"
+      # --- from missed scenarios analysis ---
+      - "started\\s+shaking"
+      - "(shaking|shook|shook)\\s+(real|really)\\s+bad"
+      - "(some\\s+kind\\s+of|had\\s+a)\\s+(fit|episode|spell|seizure|convulsion)"
+      - "(whole\\s+body|entire\\s+body).{0,15}(moving|shaking|jerking|convulsing|trembling)"
+      - "(wasn'?t|not|wouldn'?t)\\s+(respond|responding|waking|wake|answer)"
+      - "(he|she|my).{0,20}(just\\s+had|had\\s+what).{0,10}(seizure|fit|episode|convulsion)"
+      # --- witness/caregiver report ---
+      - "(saw|found|watched)\\s+(him|her|them|my)\\s+(collapse|shaking|jerking|convulsing|seizing)"
+      - "I\\s+saw\\s+(him|her|them)\\s+(shak|jerk|collaps|convuls|seiz)"
+      - "(heard|saw)\\s+a\\s+thump.{0,20}(found|floor)"
+      # --- post-ictal confusion ---
+      - "(woke up|came to)\\s+(confused|sore|hurting|on the floor|don'?t know)"
+      - "came\\s+to.{0,20}(floor|confused|didn'?t know|disoriented)"
+      - "doesn'?t\\s+remember.{0,20}(it|what|the seizure|anything|happening)"
+      - "don'?t\\s+remember.{0,20}(it happening|what happened|anything)"
+      # --- subtle seizure types / staring ---
+      - "(staring|stared).{0,15}(blankly|and (not|wasn'?t) respond|mumbl|mak)"
+      - "just\\s+(staring|sat there|stood there).{0,15}(not respond|wasn'?t|wouldn'?t)"
+      # --- aura patterns ---
+      - "(metallic|strange|weird|burnt)\\s+(taste|smell).{0,20}(then|before|and)"
+      - "deja\\s+vu.{0,15}(then|and|before|nausea)"
+      - "rising\\s+(feeling|sensation).{0,15}(stomach|then|and)"
+      # --- first/new seizure ---
+      - "(first|new)\\s+(time\\s+)?seizure"
+      - "never\\s+(had|experienced).{0,10}(a\\s+)?seizure"
+      - "(look|looked)\\s+like\\s+a\\s+seizure"
+  low:
+    partials:
+      - "seizure"
+      - "convulsion"
+      - "epileptic"
+      - "twitching"
+      - "weird feeling before I lose"
+      - "smell something strange then"
+      - "brief episode"
+      - "another episode"
+
+negation_handling:
+  patterns:
+    - "no seizures"
+    - "seizure free"
+    - "no convulsions"
+    - "didn't have a seizure"
+    - "haven't had any seizures"
+    - "haven't had seizures"
+    - "no seizure"
+    - "no shaking"
+    - "no jerking"
+    # --- R1 denial coverage ---
+    - "haven't blacked out"
+    - "didn't black out"
+    - "no blackouts"
+    - "haven't blanked out"
+    - "didn't blank out"
+    - "haven't lost consciousness"
+    - "didn't lose consciousness"
+    - "no loss of consciousness"
+    - "haven't lost any time"
+    - "haven't lost time"
+    - "no episodes"
+    - "haven't had any episodes"
+    - "haven't had a seizure"
+    - "no seizure activity"
+    - "haven't fainted or blacked out"
+    - "haven't been confused"
+    - "no confusion or anything"
+    # --- instruction/medication memory context (R1 scenarios) ---
+    - "remember the dosage"
+    - "remember what the doctor"
+    - "remember what to take"
+    - "remember the instructions"
+    - "remember the schedule"
+    - "remember which pill"
+    - "remember which medication"
+    - "remember what I was told"
+    - "remember what my"
+    - "remember if I"
+    - "pharmacy label"
+    - "prescription says"
+    - "label says"
+    - "medication question"
+    - "medication schedule"
+    - "dosing schedule"
+    - "asking about my"
+    - "question about my"
+    - "refill"
+    # --- administrative / routine context suppression ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "when can I come in"
+    - "need a refill"
+    - "routine check"
+    - "just a question"
+    # --- incontinence context (R1 post_procedure_incontinence) ---
+    - "incontinence"
+    - "urine leakage"
+    - "leaking urine"
+    - "bladder control"
+    - "bladder surgery"
+    - "prostate surgery"
+    - "prostate procedure"
+    - "pelvic floor"
+    - "wearing pads"
+    - "since the procedure"
+    - "since surgery"
+    - "since the surgery"
+    - "catheter"
+    - "appointment timing"
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_has_condition: ["G40.*"]
+      reason: "Known epilepsy — breakthrough seizure"
+    - when:
+        patient_on_medication_class: ["antiepileptics"]
+      reason: "On AED suggests seizure disorder"
diff --git a/list/taxonomy/self_harm_nonsuicidal/flows/clarify.yaml b/list/taxonomy/self_harm_nonsuicidal/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c78d1cc214a812d7fec0f29e0eae6e35394c9b8d
--- /dev/null
+++ b/list/taxonomy/self_harm_nonsuicidal/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: self_harm_nonsuicidal
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: nssi_clarify
+      goal: "Gently ask patient to describe what they mean"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "I want to make sure I understand. Could you tell me a bit more about what you're experiencing?"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - nssi_clarify_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: escalate_r2
diff --git a/list/taxonomy/self_harm_nonsuicidal/flows/escalate_r2.yaml b/list/taxonomy/self_harm_nonsuicidal/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..02b0a870fed555bf51727fea8072454f5b29b130
--- /dev/null
+++ b/list/taxonomy/self_harm_nonsuicidal/flows/escalate_r2.yaml
@@ -0,0 +1,36 @@
+flow_id: escalate_r2
+type: escalation
+domain: self_harm_nonsuicidal
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: nssi_r2_escalation_notice
+      goal: "Connect patient with mental health professional for self-harm evaluation"
+      tone: empathetic
+      must_include:
+        - "mental health"
+        - "support"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: mental_health_professional
+    urgency: same_day
+    response_spec:
+      id: nssi_r2_handoff
+      goal: "Transfer to mental health professional"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/self_harm_nonsuicidal/flows/escalate_r3.yaml b/list/taxonomy/self_harm_nonsuicidal/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6205a8f0e5a57ee93e38a51f600683dc65e9707a
--- /dev/null
+++ b/list/taxonomy/self_harm_nonsuicidal/flows/escalate_r3.yaml
@@ -0,0 +1,38 @@
+flow_id: escalate_r3
+type: escalation
+domain: self_harm_nonsuicidal
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: nssi_r3_escalation_notice
+    goal: NSSI with suicidal intent or severe medical injury — immediate crisis intervention
+    tone: calm_urgent
+    must_include:
+    - '988'
+    - call 911
+    - right now
+    - crisis
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: crisis_counselor
+  urgency: immediate
+  response_spec:
+    id: nssi_r3_handoff
+    goal: Transfer to crisis counselor
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/self_harm_nonsuicidal/flows/safety_screen.yaml b/list/taxonomy/self_harm_nonsuicidal/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..90a4457268325e00e1ebff0c5a737241b5ba2429
--- /dev/null
+++ b/list/taxonomy/self_harm_nonsuicidal/flows/safety_screen.yaml
@@ -0,0 +1,56 @@
+flow_id: safety_screen
+type: screening
+domain: self_harm_nonsuicidal
+
+required_slots:
+  - nssi_method
+  - nssi_recency
+  - nssi_si_crosscheck
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: nssi_screen_step1
+      goal: "Assess NSSI method, recency, and medical severity"
+      tone: gentle_professional
+      must_include:
+        - "understand"
+        - "safe"
+      must_ask:
+        - "Can you tell me what you've been doing to hurt yourself?"
+        - "When was the last time this happened?"
+      must_not:
+        - "don't worry"
+        - "diagnos"
+        - "why would you"
+      max_questions: 2
+    collects:
+      - nssi_method
+      - nssi_recency
+      - nssi_medical_severity
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: nssi_screen_step2
+      goal: "Cross-check for suicidal intent — C-SSRS explicitly separates NSSI from suicidal behavior"
+      tone: gentle_professional
+      must_include:
+        - "important"
+      must_ask:
+        - "When you hurt yourself, do you ever have thoughts of wanting to die?"
+      must_not:
+        - "don't worry"
+        - "diagnos"
+        - "why would you"
+      max_questions: 1
+    collects:
+      - nssi_si_crosscheck
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_r2: escalate_r2
+  on_low_risk: escalate_r2
+  on_unclear: escalate_r2
diff --git a/list/taxonomy/self_harm_nonsuicidal/rules.yaml b/list/taxonomy/self_harm_nonsuicidal/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1c76bae7b5315dadb20503a5da4445ccdafafd39
--- /dev/null
+++ b/list/taxonomy/self_harm_nonsuicidal/rules.yaml
@@ -0,0 +1,33 @@
+domain: self_harm_nonsuicidal
+target_risk_class: R2
+
+decision_rules:
+  - id: nssi_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: nssi_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: nssi_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: nssi_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: nssi_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/self_harm_nonsuicidal/triggers.yaml b/list/taxonomy/self_harm_nonsuicidal/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..04884959d453fa65540982ce1b9e797760e20a31
--- /dev/null
+++ b/list/taxonomy/self_harm_nonsuicidal/triggers.yaml
@@ -0,0 +1,69 @@
+domain: self_harm_nonsuicidal
+priority: 80
+
+lexical_signals:
+  high:
+    phrases:
+      - "cutting myself"
+      - "burn myself"
+      - "burning myself"
+      - "hurting myself on purpose"
+      - "hitting myself"
+      - "scratching myself until I bleed"
+      - "banging my head against the wall"
+      - "punching walls to feel pain"
+      - "cutting my arms"
+      - "cutting my legs"
+      - "I've been cutting"
+    regex:
+      - "(cut|cutting|burn|burning|hit|hitting|scratch|scratching|bang|banging)\\s+(myself|my\\s+(arm|leg|wrist|thigh|skin))"
+      - "(hurt|hurting|harm|harming)\\s+(myself)\\s+(on\\s+purpose|intentionally|deliberately)"
+      - "self.?harm"
+  medium:
+    phrases:
+      - "self-harm"
+      - "marks on my arms"
+      - "marks on my legs"
+      - "it helps me feel"
+      - "it helps me cope"
+      - "I do it to feel something"
+      - "I do it to feel better"
+      - "the pain helps"
+      - "I need the pain"
+      - "scars on my arms"
+      - "fresh cuts"
+      - "new marks"
+      - "been hurting myself"
+    regex:
+      - "(marks?|scars?|cuts?|burns?|bruises?)\\s+(on|all over)\\s+(my\\s+)?(arm|leg|wrist|thigh|body)"
+      - "(it|pain|cutting|burning)\\s+(helps|makes)\\s+(me\\s+)?(feel|cope|calm|better|something)"
+      - "(fresh|new|recent)\\s+(cuts?|marks?|wounds?|burns?|scars?)"
+      - "been\\s+(hurting|cutting|burning|harming)\\s+(myself|my)"
+  low:
+    partials:
+      - "cutting"
+      - "self-injury"
+      - "self harm"
+      - "hurting myself"
+      - "harm myself"
+
+negation_handling:
+  patterns:
+    - "stopped cutting"
+    - "haven't cut in"
+    - "no longer cutting"
+    - "used to cut"
+    - "cut myself off"
+    - "cut myself some slack"
+    - "cutting calories"
+    - "cutting back"
+    - "cut myself cooking"
+    - "cut myself shaving"
+    - "accidentally cut"
+    - "paper cut"
+    - "no thoughts of self-harm"
+    - "no self-harm"
+    - "not self-harming"
+    - "no thoughts of hurting myself"
+    - "don't want to hurt myself"
+  action: downgrade_confidence
diff --git a/list/taxonomy/severe_abdominal_pain/flows/clarify.yaml b/list/taxonomy/severe_abdominal_pain/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8dfc648fa0222b25d398da3a2158e1def90008de
--- /dev/null
+++ b/list/taxonomy/severe_abdominal_pain/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: severe_abdominal_pain
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: severe_abdominal_pain_clarify
+      goal: "Ask patient to describe their severe abdominal pain symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - severe_abdominal_pain_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/severe_abdominal_pain/flows/escalate_r2.yaml b/list/taxonomy/severe_abdominal_pain/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d8a2729ef3ec2bd3ca1b6f476249089b4cd69ce2
--- /dev/null
+++ b/list/taxonomy/severe_abdominal_pain/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: severe_abdominal_pain
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/severe_abdominal_pain/flows/handoff.yaml b/list/taxonomy/severe_abdominal_pain/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..57a56295aabd84efbec43a74cd8599a0029a5ecc
--- /dev/null
+++ b/list/taxonomy/severe_abdominal_pain/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: severe_abdominal_pain
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: severe_abdominal_pain_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: severe_abdominal_pain_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/severe_abdominal_pain/flows/safety_screen.yaml b/list/taxonomy/severe_abdominal_pain/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..43eafaff9d97eb0546ca273eece3fd923bf00fae
--- /dev/null
+++ b/list/taxonomy/severe_abdominal_pain/flows/safety_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: safety_screen
+type: screening
+domain: severe_abdominal_pain
+
+required_slots:
+  - pain_location
+  - pain_onset
+  - pain_severity
+  - associated_symptoms
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "pain location"
+        - "pain onset"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - pain_location
+      - pain_onset
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "pain severity"
+        - "associated symptoms"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - pain_severity
+      - associated_symptoms
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/list/taxonomy/severe_abdominal_pain/rules.yaml b/list/taxonomy/severe_abdominal_pain/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..804c41d114864aa129606a33ceba178d5e99e63f
--- /dev/null
+++ b/list/taxonomy/severe_abdominal_pain/rules.yaml
@@ -0,0 +1,27 @@
+domain: severe_abdominal_pain
+target_risk_class: R2
+
+decision_rules:
+  - id: severe_abdominal_pain_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: severe_abdominal_pain_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: severe_abdominal_pain_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: severe_abdominal_pain_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/severe_abdominal_pain/triggers.yaml b/list/taxonomy/severe_abdominal_pain/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0ddb90caaa519d5427e26414aea9e11d641d053b
--- /dev/null
+++ b/list/taxonomy/severe_abdominal_pain/triggers.yaml
@@ -0,0 +1,171 @@
+domain: severe_abdominal_pain
+priority: 78
+
+lexical_signals:
+  high:
+    phrases:
+      # --- ORIGINAL ---
+      - "severe abdominal pain"
+      - "stomach pain is unbearable"
+      - "worst belly pain"
+      - "abdomen is rigid"
+      - "severe cramping in my stomach"
+      - "acute abdominal pain"
+      # --- EXPANDED naturalistic ---
+      - "belly hurts so bad I can't move"
+      - "doubled over in pain"
+      - "can't stand up straight from the pain"
+      - "worst stomach pain I've ever had"
+      - "worst stomach pain of my life"
+      - "stomach pain is a 10 out of 10"
+      - "stomach pain is excruciating"
+      - "pain in my gut is unbearable"
+      - "abdominal pain and I can't move"
+      - "pain so bad I'm screaming"
+      - "sharp stabbing pain in my stomach"
+      - "my stomach feels like it's ripping apart"
+      - "abdominal pain is getting much worse"
+      - "stomach hurts so bad I'm crying"
+      - "my belly is so tender I can't touch it"
+      - "abdomen is hard and painful"
+      - "stomach pain and I feel like I'm going to pass out"
+    regex:
+      # --- ORIGINAL ---
+      - "severe\\s+(abdominal|stomach|belly)\\s+pain"
+      # --- EXPANDED ---
+      - "(stomach|belly|abdom|gut).{0,15}(unbearable|excruciating|worst|terrible|horrible|agonizing|10\\s+out\\s+of|10/10)"
+      - "(doubled|bent|hunched|curled)\\s+(over|up)\\s+(in|with|from)\\s+(the\\s+)?pain"
+      - "(can'?t|cannot|unable\\s+to)\\s+(stand|sit|move|walk|straighten|get\\s+up).{0,15}(pain|hurt|stomach|belly)"
+      - "pain.{0,15}(so\\s+bad|so\\s+intense|so\\s+severe).{0,20}(scream|cry|throw\\s+up|can'?t)"
+      - "(sharp|stabbing|tearing|ripping|knife).{0,10}(pain|feeling).{0,15}(stomach|belly|abdom|gut|side)"
+      - "(stomach|belly|abdom).{0,10}(feels?|is)\\s+(like\\s+)?(ripping|tearing|on\\s+fire|being\\s+stabbed)"
+      - "(stomach|belly|abdom).{0,15}(rigid|hard|distended|swollen).{0,15}(and\\s+)?pain"
+      - "(worst|most\\s+intense|most\\s+severe).{0,10}(stomach|belly|abdom|gut)\\s+pain"
+      - "(stomach|belly|abdom|gut)\\s+pain.{0,15}(pass\\s+out|faint|vomit|throw\\s+up)"
+      - "(tender|can'?t\\s+touch).{0,15}(stomach|belly|abdom)"
+  medium:
+    phrases:
+      # --- ORIGINAL ---
+      - "bad stomach pain"
+      - "really hurts in my belly"
+      - "abdominal pain getting worse"
+      - "constant stomach pain"
+      - "sharp pain in abdomen"
+      - "stomach pain won't go away"
+      # --- EXPANDED naturalistic ---
+      - "pain in my gut"
+      - "stomach is killing me"
+      - "belly is really hurting"
+      - "my stomach won't stop cramping"
+      - "cramping really bad"
+      - "sharp abdominal pain"
+      - "stomach pain since I got home"
+      - "stomach pain that comes and goes but it's bad"
+      - "woke up with terrible stomach pain"
+      - "pain all across my abdomen"
+      - "lower belly pain"
+      - "upper stomach pain"
+      - "pain on the right side of my belly"
+      - "pain on the left side of my belly"
+      - "stomach cramps are getting worse"
+      - "burning pain in my stomach"
+      - "deep ache in my belly"
+      - "feels like something is wrong in my stomach"
+      - "stomach pain after eating"
+      - "stomach hurts really bad"
+      - "belly is in a lot of pain"
+      - "gut feels like it's on fire"
+      - "throbbing pain in my abdomen"
+      - "nausea and bad stomach pain"
+      - "stomach pain and vomiting"
+      # --- additional patterns ---
+      - "guarding my belly"
+      - "can't let anyone touch my stomach"
+      - "pain is worse when I move"
+      - "every bump in the road makes it worse"
+    regex:
+      # --- EXPANDED ---
+      - "(stomach|belly|gut|abdom).{0,10}(is\\s+)?(killing|destroying|wrecking)\\s+(me|him|her)"
+      - "(stomach|belly|abdom|gut).{0,10}(really|very|so|super)\\s+(hurt|pain|sore|tender)"
+      - "(stomach|belly|abdom)\\s+(won'?t|doesn'?t)\\s+stop\\s+(cramp|hurt|ach)"
+      - "(cramp|spasm).{0,10}(really|very|so|pretty)\\s+bad"
+      - "(sharp|burning|throbbing|deep|dull).{0,10}(pain|ache).{0,15}(stomach|belly|abdom|gut|side)"
+      - "(pain|ache|hurt).{0,10}(in|across|all\\s+over)\\s+(my\\s+)?(abdom|stomach|belly|gut)"
+      - "(woke\\s+up|came\\s+on|started).{0,15}(terrible|bad|awful|horrible)\\s+(stomach|belly|abdom)\\s+pain"
+      - "(stomach|belly|abdom)\\s+pain.{0,15}(worse|worsening|increasing|intensif)"
+      - "(lower|upper|right|left).{0,10}(stomach|belly|abdom|side)\\s+(pain|hurt|ache|cramp)"
+      - "(nausea|vomit|throw).{0,20}(stomach|belly|abdom)\\s+(pain|hurt|ache)"
+      - "(stomach|belly|abdom)\\s+(pain|hurt|ache).{0,20}(nausea|vomit|throw)"
+      - "(feels?|something).{0,10}(wrong|off).{0,10}(stomach|belly|gut|abdom|inside)"
+      - "(belly|stomach|abdom).{0,15}(pain|hurt|ache).{0,20}(wave|comes\\s+and\\s+goes|spike|intense)"
+      - "(curl|curled)\\s+(up|into).{0,15}(pain|stomach|belly)"
+      - "(threw|throw)\\s+up.{0,20}(stomach|belly|abdom|pain)"
+    partials:
+      - "stomach killing me"
+      - "gut pain"
+      - "side pain"
+      - "cramping bad"
+      - "belly cramping"
+  low:
+    partials:
+      # --- ORIGINAL ---
+      - "stomach hurts"
+      - "belly pain"
+      - "abdominal discomfort"
+      # --- EXPANDED ---
+      - "stomach pain"
+      - "stomach ache"
+      - "stomachache"
+      - "abdominal pain"
+      - "gut hurts"
+      - "belly hurts"
+      - "tummy pain"
+      - "tummy ache"
+      - "cramping"
+      - "abdominal cramps"
+      - "stomach cramps"
+      - "stomach tender"
+      - "belly sore"
+      - "epigastric"
+      - "periumbilical"
+      - "flank pain"
+
+negation_handling:
+  patterns:
+    # --- ORIGINAL ---
+    - "no abdominal pain"
+    - "stomach feels fine"
+    - "belly pain is gone"
+    # --- EXPANDED ---
+    - "no stomach pain"
+    - "no belly pain"
+    - "abdominal pain resolved"
+    - "stomach pain resolved"
+    - "stomach pain went away"
+    - "stomach pain is better"
+    - "stomach pain is improving"
+    - "belly pain getting better"
+    - "pain is manageable"
+    - "abdominal pain much better"
+    - "stomach doesn't hurt anymore"
+    - "belly is fine now"
+    - "no more cramping"
+    - "cramps have stopped"
+    - "stomach feels okay"
+    - "stomach feels normal"
+    - "abdominal pain is gone"
+    - "pain went away on its own"
+    - "pain is mild"
+    - "just a little sore"
+    - "only hurts when I press on it"
+    - "only tender to touch"
+    - "mild discomfort"
+    - "stomach is settling down"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
diff --git a/list/taxonomy/severe_bleeding/flows/clarify.yaml b/list/taxonomy/severe_bleeding/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ab5385d0ac8bbea5434bcd1434b52af856f42f1d
--- /dev/null
+++ b/list/taxonomy/severe_bleeding/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: severe_bleeding
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: severe_bleeding_clarify
+      goal: "Ask patient to describe their severe bleeding symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - severe_bleeding_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/severe_bleeding/flows/escalate_r3.yaml b/list/taxonomy/severe_bleeding/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..126ba10d89c92b3506041cb1f940b4c6ff5c2551
--- /dev/null
+++ b/list/taxonomy/severe_bleeding/flows/escalate_r3.yaml
@@ -0,0 +1,38 @@
+flow_id: escalate_r3
+type: escalation
+domain: severe_bleeding
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Inform patient this requires immediate clinical attention and they will
+      be transferred
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/severe_bleeding/flows/handoff.yaml b/list/taxonomy/severe_bleeding/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b4bebc55d92662bb365493444d106a7b1b6f08ba
--- /dev/null
+++ b/list/taxonomy/severe_bleeding/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: severe_bleeding
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: severe_bleeding_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: severe_bleeding_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/severe_bleeding/rules.yaml b/list/taxonomy/severe_bleeding/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..969b81cc35c632bbd72eb598262b6416e2f920e6
--- /dev/null
+++ b/list/taxonomy/severe_bleeding/rules.yaml
@@ -0,0 +1,21 @@
+domain: severe_bleeding
+target_risk_class: R3
+
+decision_rules:
+  - id: severe_bleeding_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r3
+
+  - id: severe_bleeding_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r3
+
+  - id: severe_bleeding_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/severe_bleeding/triggers.yaml b/list/taxonomy/severe_bleeding/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b04d59736dd39d4e41a3043e3f8b5145ea775bf9
--- /dev/null
+++ b/list/taxonomy/severe_bleeding/triggers.yaml
@@ -0,0 +1,108 @@
+domain: severe_bleeding
+priority: 96
+
+lexical_signals:
+  high:
+    phrases:
+      - "won't stop bleeding"
+      - "bleeding heavily"
+      - "blood soaking through"
+      - "hemorrhaging"
+      - "spurting blood"
+      - "can't control the bleeding"
+      - "bleeding profusely"
+      - "blood everywhere"
+      - "bleeding through the bandage"
+      - "blood is pouring out"
+      - "soaked through the gauze"
+      - "massive bleeding"
+      - "lost a lot of blood"
+      - "bleeding really bad"
+      - "blood won't stop coming"
+      - "gushing blood"
+    regex:
+      - "(won'?t|can'?t)\\s+stop\\s+bleeding"
+      - "hemorrhag"
+      - "bleed(ing)?\\s+(heavy|heav|bad|profuse|a\\s+lot|really|so\\s+much|through|massive)"
+      - "a lot of\\s+bleed"
+      - "(soak|soaked|soaking)\\s+(through|the)"
+      - "blood\\s+(everywhere|pouring|gushing|won'?t)"
+      - "bleed(ing)?.{0,15}(not|isn'?t|won'?t).{0,10}(stop|slow|let|clot)"
+      # --- caregiver/indirect ---
+      - "(so much|all this|too much)\\s+blood"
+      # --- quantity indicators ---
+      - "(pooling|pool of)\\s+blood"
+      - "blood\\s+(pooling|collecting|accumulating)"
+      - "(drenched|saturated|sopping)\\s+(in|with)\\s+blood"
+      # --- visual severity ---
+      - "blood\\s+(spurting|squirting|shooting)"
+      - "(arterial|pulsing|pulsating)\\s+bleed"
+      # --- caregiver reports ---
+      - "(he|she|they|my (husband|wife|child|kid|mom|dad|son|daughter))('s|\\s+is)?\\s+bleeding\\s+(bad|heavy|a lot|so much|profuse)"
+      - "there('s|\\s+is)\\s+(so much|a lot of|too much)\\s+blood"
+      # --- location + severity ---
+      - "(head|scalp|face)\\s+(wound|cut|gash).{0,20}(bleed|blood)"
+      - "(deep|large|bad)\\s+(cut|gash|laceration).{0,20}(bleed|blood|won'?t stop)"
+  medium:
+    phrases:
+      - "a lot of blood"
+      - "bleeding from incision"
+      - "wound is bleeding again"
+      - "blood coming through bandage"
+      - "continuous bleeding"
+      - "blood won't clot"
+      - "still bleeding"
+      - "incision is oozing"
+      - "bleeding from the surgical site"
+      - "blood on my clothes"
+      - "dripping blood"
+      - "bleeding more than before"
+      - "there's blood"
+      - "a fair amount of bleeding"
+      - "bright red bleeding"
+      - "enough to drip"
+      - "nose and mouth are bleeding"
+      - "cut and it's bleeding"
+      - "a lot of bleeding"
+      - "bright red blood"
+      - "blood in the toilet"
+      - "blood on the floor"
+      - "bleeding from my rectum"
+      - "bleeding from my butt"
+      - "way more than normal"
+    regex:
+      - "(blood|bleed).{0,20}(a lot|fair amount|quite a bit|drip|splash|bright red)"
+      - "bright\\s+red\\s+(blood|bleed)"
+      - "(nose|mouth|gums|ear|rectum|rectal|butt|bottom|vagina|vaginal).{0,15}(bleed|blood)"
+      - "bleed(ing)?\\s+(from|out of)\\s+(my\\s+)?(rectum|butt|bottom|nose|mouth|ear|gums|vagina|incision|cut|wound)"
+      - "(cut|wound|incision|lacerat).{0,35}(bleed|blood)"
+      - "blood\\s+(in|all over)\\s+(the\\s+)?(toilet|bowl|water|sink|tub|floor)"
+      - "a lot of.{0,15}blood"
+      - "bleed(ing)?\\s+a\\s+(bit|little).{0,30}(not|isn'?t|won'?t).{0,10}(stop|slow|clot)"
+  low:
+    partials:
+      - "bleeding"
+      - "blood loss"
+      - "hemorrhage"
+      - "a lot of blood"
+
+negation_handling:
+  patterns:
+    - "bleeding stopped"
+    - "no more bleeding"
+    - "bleeding is controlled"
+    # --- administrative / routine context suppression ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "when can I come in"
+    - "medication refill"
+    - "need a refill"
+    - "routine check"
+    - "just a question"
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_on_medication_class: ["anticoagulants", "antiplatelets"]
+      reason: "Anticoagulation increases bleeding severity"
diff --git a/list/taxonomy/severe_diarrhea/flows/clarify.yaml b/list/taxonomy/severe_diarrhea/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0eb33b16c5365ca0f835b5929f56e7ccb1c30c27
--- /dev/null
+++ b/list/taxonomy/severe_diarrhea/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: severe_diarrhea
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: severe_diarrhea_clarify
+      goal: "Ask patient to describe their severe diarrhea symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - severe_diarrhea_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/severe_diarrhea/flows/escalate_r2.yaml b/list/taxonomy/severe_diarrhea/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b9771d3a0bfcc4f98772210287db59f97557d6b5
--- /dev/null
+++ b/list/taxonomy/severe_diarrhea/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: severe_diarrhea
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/severe_diarrhea/flows/handoff.yaml b/list/taxonomy/severe_diarrhea/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d8b5f6efc3a5357c813f882305fa3b42a787b363
--- /dev/null
+++ b/list/taxonomy/severe_diarrhea/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: severe_diarrhea
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: severe_diarrhea_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: severe_diarrhea_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/severe_diarrhea/flows/safety_screen.yaml b/list/taxonomy/severe_diarrhea/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..1fe73098f29a8395189d04df6b9dbe79547da7f9
--- /dev/null
+++ b/list/taxonomy/severe_diarrhea/flows/safety_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: safety_screen
+type: screening
+domain: severe_diarrhea
+
+required_slots:
+  - diarrhea_frequency
+  - duration
+  - fluid_intake
+  - dehydration_signs
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "diarrhea frequency"
+        - "duration"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - diarrhea_frequency
+      - duration
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "fluid intake"
+        - "dehydration signs"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - fluid_intake
+      - dehydration_signs
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/list/taxonomy/severe_diarrhea/rules.yaml b/list/taxonomy/severe_diarrhea/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d6fcce3e47d0de87842d56ad6241fbe84eb1febb
--- /dev/null
+++ b/list/taxonomy/severe_diarrhea/rules.yaml
@@ -0,0 +1,27 @@
+domain: severe_diarrhea
+target_risk_class: R2
+
+decision_rules:
+  - id: severe_diarrhea_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: severe_diarrhea_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: severe_diarrhea_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: severe_diarrhea_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/severe_diarrhea/triggers.yaml b/list/taxonomy/severe_diarrhea/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..098be4551815904951ec471b0f6f1992c9c3f81d
--- /dev/null
+++ b/list/taxonomy/severe_diarrhea/triggers.yaml
@@ -0,0 +1,186 @@
+domain: severe_diarrhea
+priority: 65
+
+lexical_signals:
+  high:
+    phrases:
+      # --- ORIGINAL ---
+      - "diarrhea won't stop and I'm dehydrated"
+      - "severe diarrhea and can't keep fluids down"
+      - "watery diarrhea all day and feeling faint"
+      - "diarrhea 10 times today"
+      - "C. diff symptoms"
+      - "severe diarrhea since discharge"
+      # --- EXPANDED naturalistic ---
+      - "can't leave the bathroom"
+      - "running to the bathroom every few minutes"
+      - "I'm on the toilet constantly"
+      - "diarrhea won't stop"
+      - "going every 20 minutes"
+      - "going every 30 minutes"
+      - "liquid coming out of me nonstop"
+      - "diarrhea and I can't keep anything down"
+      - "watery diarrhea with blood"
+      - "diarrhea and I feel like I'm going to pass out"
+      - "I've had diarrhea all day and I'm getting weak"
+      - "I've lost count of how many times I've gone"
+      - "can't make it to the bathroom in time"
+      - "having accidents because the diarrhea is so bad"
+      - "stomach is emptying and it won't stop"
+      - "nothing but water coming out"
+      - "diarrhea more than 10 times"
+      - "watery diarrhea since I got home from the hospital"
+    regex:
+      # --- ORIGINAL ---
+      - "severe\\s+diarrhea"
+      - "diarrhea.*(dehydrat|faint|can'?t\\s+keep)"
+      # --- EXPANDED ---
+      - "(can'?t|cannot)\\s+(leave|get\\s+off|get\\s+away\\s+from)\\s+(the\\s+)?(bathroom|toilet)"
+      - "(running|rushing|going)\\s+(to|back\\s+to)\\s+(the\\s+)?(bathroom|toilet)"
+      - "(on\\s+the\\s+toilet|in\\s+the\\s+bathroom)\\s+(all\\s+day|constantly|nonstop|non-stop|every)"
+      - "(going|diarrhea|runs).{0,15}every\\s+\\d+\\s+(minutes?|mins?|hours?|hrs?)"
+      - "(diarrhea|stool|bowel).{0,15}(won'?t|doesn'?t|will\\s+not)\\s+stop"
+      - "(liquid|watery|water)\\s+(stool|coming\\s+out|diarrhea|bowel)"
+      - "(can'?t|cannot)\\s+(make\\s+it|get|be\\s+away)\\s+(to|from)\\s+(the\\s+)?(bathroom|toilet)"
+      - "(accident|soil|mess).{0,20}(diarrhea|bowel|bathroom|can'?t\\s+make)"
+      - "diarrhea.{0,20}(blood|bloody|red|black|tarry)"
+      - "(\\d{2,}|ten|twelve|fifteen|twenty)\\s+(times?|episodes?|bouts?|trips?)"
+      - "lost\\s+count.{0,15}(times|how\\s+many|bathroom|gone)"
+      - "nothing\\s+but\\s+(water|liquid)\\s+(coming|is\\s+coming)\\s+out"
+      - "(explosive|uncontrollable|non-?stop|nonstop)\\s+(diarrhea|bowel|stool)"
+  medium:
+    phrases:
+      # --- ORIGINAL ---
+      - "diarrhea and feeling dehydrated"
+      - "loose stools many times a day"
+      - "can't stop having diarrhea"
+      - "diarrhea since discharge"
+      - "watery diarrhea and weak"
+      - "diarrhea with cramping"
+      # --- EXPANDED naturalistic ---
+      - "running to the bathroom"
+      - "watery diarrhea"
+      - "liquid stool"
+      - "diarrhea keeps coming back"
+      - "still having diarrhea"
+      - "diarrhea is getting worse"
+      - "stomach is just gurgling and everything comes out liquid"
+      - "going to the bathroom a lot more than normal"
+      - "bowels are all messed up since I got home"
+      - "can't eat anything without getting diarrhea"
+      - "loose stools with cramping"
+      - "diarrhea and stomach cramps"
+      - "diarrhea with nausea"
+      - "I keep having the runs"
+      - "stools are completely liquid"
+      - "diarrhea and feel really weak"
+      - "been going to the bathroom nonstop"
+      - "my gut is a mess"
+      - "the antibiotic is giving me bad diarrhea"
+      - "started having diarrhea after I started the new medication"
+      - "diarrhea and my stomach won't stop cramping"
+      # --- MINIMIZER coverage ---
+      - "just a bit of an upset stomach"
+      - "probably something I ate"
+      - "it's not that bad, just going a bit more than usual"
+      - "stomach is just a little off"
+      - "bowels are just a bit loose"
+      - "just have the runs, probably nothing"
+      - "a little diarrhea but I'm managing"
+      - "stomach has been kind of funny"
+      - "going to the bathroom more than normal"
+      - "stools are a bit looser than usual"
+      # --- additional dehydration signals ---
+      - "dizzy from the diarrhea"
+      - "lips are dry and I keep going"
+      - "haven't been able to drink enough"
+    regex:
+      # --- EXPANDED ---
+      - "(watery|liquid|loose|runny)\\s+(stool|bowel|diarrhea|poop|movement)"
+      - "diarrhea.{0,20}(worse|getting\\s+worse|increasing|more\\s+frequent)"
+      - "diarrhea.{0,20}(cramp|nausea|vomit|weak|pain)"
+      - "(can'?t|cannot)\\s+eat.{0,15}(without|diarrhea|get)"
+      - "(the\\s+)?(runs|trots)\\s+(won'?t|keep|all\\s+day)"
+      - "(keep|keeps|kept)\\s+(having|getting)\\s+(the\\s+)?(runs|diarrhea|loose\\s+stool)"
+      - "(gut|bowel|stomach|belly).{0,10}(mess|messed|torn\\s+up|tore\\s+up)"
+      - "(antibiotic|medication|medicine|drug).{0,20}diarrhea"
+      - "diarrhea.{0,20}(antibiotic|medication|medicine|new\\s+med)"
+      - "(stool|bowel\\s+movement).{0,10}(completely|all|just|nothing\\s+but)\\s+(liquid|water)"
+      - "bathroom\\s+(nonstop|non-?stop|all\\s+day|all\\s+night|constantly)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(just|only).{0,10}(a\\s+)?(little|bit|touch).{0,10}(diarrhea|loose|upset|off|funny|runny)"
+      - "(probably|might be).{0,10}(just|nothing|something I ate|food|bug).{0,15}(diarrhea|stomach|bowel|loose)"
+      - "(stomach|bowel|gut|tummy).{0,10}(a\\s+)?(bit|little|kind of|sort of).{0,10}(off|upset|funny|loose|messed|dodgy)"
+      - "(going|bathroom|toilet).{0,15}(more|a lot|a bit more|more often).{0,10}(than usual|than normal|lately|today)"
+      - "(stool|bowel).{0,10}(a\\s+)?(bit|little|kind of).{0,10}(loose|watery|runny|soft)"
+    partials:
+      - "the runs"
+      - "running to the bathroom"
+      - "stomach bug"
+      - "loose bowels"
+      - "bowel problems"
+  low:
+    partials:
+      # --- ORIGINAL ---
+      - "diarrhea"
+      - "loose stools"
+      - "watery stool"
+      # --- EXPANDED ---
+      - "loose bowel"
+      - "frequent stools"
+      - "liquid stool"
+      - "the runs"
+      - "upset stomach"
+      - "bowel issues"
+      - "going a lot"
+      - "runny stool"
+      - "C. diff"
+      - "cdiff"
+      - "clostridium"
+      - "colitis"
+      - "GI issues"
+
+negation_handling:
+  patterns:
+    # --- ORIGINAL ---
+    - "diarrhea stopped"
+    - "stools normalizing"
+    - "no diarrhea"
+    # --- EXPANDED ---
+    - "diarrhea resolved"
+    - "diarrhea is better"
+    - "diarrhea is improving"
+    - "stools are firming up"
+    - "stools are more formed"
+    - "bowels are back to normal"
+    - "bowel movements are normal"
+    - "diarrhea went away"
+    - "no more diarrhea"
+    - "no loose stools"
+    - "not having diarrhea anymore"
+    - "diarrhea has cleared up"
+    - "only one or two loose stools"
+    - "diarrhea much better"
+    - "stomach is settling down"
+    - "stools are solid now"
+    - "stool is formed"
+    - "bathroom trips back to normal"
+    - "no more loose stools"
+    - "no more watery stools"
+    - "stopped having diarrhea"
+    # --- incontinence frequency context (R1 post_procedure_incontinence) ---
+    - "incontinence"
+    - "incontinence episodes"
+    - "leaking episodes"
+    - "urine leakage"
+    - "urine leakage episodes"
+    - "leaking urine"
+    - "pad changes"
+    - "wearing pads"
+    - "bladder control"
+    - "pelvic floor"
+    - "bladder surgery"
+    - "prostate surgery"
+    - "prostate procedure"
+    - "catheter"
+  action: downgrade_confidence
diff --git a/list/taxonomy/severe_hypoglycemia/flows/clarify.yaml b/list/taxonomy/severe_hypoglycemia/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..b33a0a41349df83197bee133d4997ad5c6b869a0
--- /dev/null
+++ b/list/taxonomy/severe_hypoglycemia/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: severe_hypoglycemia
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: severe_hypoglycemia_clarify
+      goal: "Ask patient to describe their severe hypoglycemia symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - severe_hypoglycemia_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/severe_hypoglycemia/flows/escalate_r3.yaml b/list/taxonomy/severe_hypoglycemia/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4c84f2b3b344b45526c3cfc7c89e20519f007f97
--- /dev/null
+++ b/list/taxonomy/severe_hypoglycemia/flows/escalate_r3.yaml
@@ -0,0 +1,38 @@
+flow_id: escalate_r3
+type: escalation
+domain: severe_hypoglycemia
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Inform patient this requires immediate clinical attention and they will
+      be transferred
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/severe_hypoglycemia/flows/handoff.yaml b/list/taxonomy/severe_hypoglycemia/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..02b5ba57fbb29abb85028225102de0d57edfb5bd
--- /dev/null
+++ b/list/taxonomy/severe_hypoglycemia/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: severe_hypoglycemia
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: severe_hypoglycemia_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: severe_hypoglycemia_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/severe_hypoglycemia/rules.yaml b/list/taxonomy/severe_hypoglycemia/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7ae698b90608a087adbdde20a17f53fdcc26a462
--- /dev/null
+++ b/list/taxonomy/severe_hypoglycemia/rules.yaml
@@ -0,0 +1,21 @@
+domain: severe_hypoglycemia
+target_risk_class: R3
+
+decision_rules:
+  - id: severe_hypoglycemia_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r3
+
+  - id: severe_hypoglycemia_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r3
+
+  - id: severe_hypoglycemia_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/severe_hypoglycemia/triggers.yaml b/list/taxonomy/severe_hypoglycemia/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3490318b55ec337e7321889417fa400a8ba97192
--- /dev/null
+++ b/list/taxonomy/severe_hypoglycemia/triggers.yaml
@@ -0,0 +1,125 @@
+domain: severe_hypoglycemia
+priority: 87
+
+lexical_signals:
+  high:
+    phrases:
+      - "blood sugar dangerously low"
+      - "severe hypoglycemia"
+      - "sugar dropped and confused"
+      - "blood sugar below 40"
+      - "low blood sugar and can't think straight"
+      - "hypoglycemic and disoriented"
+      - "sugar is crashing"
+      - "blood sugar is dropping"
+    regex:
+      - "(severe|dangerous)\\s+hypoglycemia"
+      - "blood\\s+sugar\\s+(below|under)\\s+\\d{2}\\b"
+      - "sugar.{0,20}(crash|drop|dip|low|plummet|tanking)"
+      - "(shaky|shaking|trembl).{0,30}(sweat|perspir).{0,30}(confus|dizzy|can't think|foggy)"
+      - "(meter|glucometer|reading|glucose|sugar).{0,25}\\b([2-4]\\d|5[0-3])\\s*(mg|mg/dl)"
+      - "\\b([2-4]\\d|5[0-3])\\s*mg.{0,5}dl"
+      - "(type\\s+1|T1D|insulin|pump).{0,40}(shak|sweat|foggy|dizzy|wobbly|off|weak)"
+  medium:
+    phrases:
+      - "blood sugar very low"
+      - "low sugar and shaking"
+      - "hypoglycemic episode"
+      - "sugar crashed"
+      - "feeling very shaky and sweating"
+      - "blood sugar dropped significantly"
+      - "my sugar is doing that bad dip thing"
+      - "shaky and sweaty"
+      - "sweaty and shaky"
+      - "can't think straight and shaky"
+      - "hands are shaking and sweating"
+      - "sugar is low"
+      - "my sugar dropped"
+      - "meter says"
+      - "insulin pump and shaky"
+      - "diabetes and shaky"
+      - "diabetes and sweating"
+    regex:
+      - "(shak|trembl).{0,20}(sweat|perspir)"
+      - "(sweat).{0,20}(shak|trembl)"
+      - "sugar.{0,15}(low|drop|dip|bad)"
+      - "my sugar.{0,20}(doing|acting|going)"
+      - "(dizzy|lightheaded|foggy|confused).{0,20}(shak|sweat)"
+  low:
+    partials:
+      - "hypoglycemia"
+      - "low sugar"
+      - "low blood sugar"
+      - "sugar low"
+      - "blood sugar"
+      - "shaky and sweaty"
+
+negation_handling:
+  patterns:
+    - "blood sugar is normal"
+    - "sugar is fine"
+    - "no hypoglycemia"
+    # --- glucose_out_of_range (R1) mild/routine context ---
+    - "blood sugar a little high"
+    - "blood sugar a bit high"
+    - "sugar a little high"
+    - "sugar a bit high"
+    - "blood sugar running high"
+    - "sugar running high"
+    - "blood sugar out of range"
+    - "glucose out of range"
+    - "blood sugar numbers are off"
+    - "sugar numbers are off"
+    - "not dangerously low"
+    - "not that low"
+    - "sugar is just a bit off"
+    - "sugar readings have been"
+    - "checking blood sugar"
+    - "blood sugar has been"
+    - "monitoring my sugar"
+    - "tracking my blood sugar"
+    - "sugar has been a little"
+    - "blood sugar slightly"
+    - "no shaking"
+    - "no sweating"
+    - "not shaky"
+    - "not sweating"
+    - "feeling fine otherwise"
+    - "I feel fine"
+    - "just the numbers"
+    # --- routine diabetes management context ---
+    - "A1C"
+    - "hemoglobin A1C"
+    - "metformin"
+    - "managing my diabetes"
+    - "diabetes management"
+    - "my doctor told me to check"
+    - "routine glucose check"
+    - "glucose readings"
+    - "blood sugar readings"
+    - "been checking my blood sugar"
+    - "been monitoring"
+    - "in the 140s"
+    - "in the 150s"
+    - "in the 160s"
+    - "in the 170s"
+    - "in the 180s"
+    - "readings have been"
+    - "adjusting my medication"
+    - "dosing question"
+    - "energy levels are normal"
+    - "energy levels are fine"
+    - "feel fine physically"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_on_medication_class: ["insulin", "sulfonylureas"]
+      reason: "High-risk hypoglycemia medications"
diff --git a/list/taxonomy/shortness_of_breath_rest/flows/clarify.yaml b/list/taxonomy/shortness_of_breath_rest/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f9457b3a22f3613bd284a286f6aeed4d72d7688a
--- /dev/null
+++ b/list/taxonomy/shortness_of_breath_rest/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: shortness_of_breath_rest
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: shortness_of_breath_rest_clarify
+      goal: "Ask patient to describe their shortness of breath rest symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - shortness_of_breath_rest_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/shortness_of_breath_rest/flows/escalate_r3.yaml b/list/taxonomy/shortness_of_breath_rest/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c6d1def50635e23e36703b4441962f85cbecbdde
--- /dev/null
+++ b/list/taxonomy/shortness_of_breath_rest/flows/escalate_r3.yaml
@@ -0,0 +1,38 @@
+flow_id: escalate_r3
+type: escalation
+domain: shortness_of_breath_rest
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Inform patient this requires immediate clinical attention and they will
+      be transferred
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/shortness_of_breath_rest/flows/handoff.yaml b/list/taxonomy/shortness_of_breath_rest/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d298d530cd73e797d02c908dbbc698692edce81d
--- /dev/null
+++ b/list/taxonomy/shortness_of_breath_rest/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: shortness_of_breath_rest
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: shortness_of_breath_rest_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: shortness_of_breath_rest_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/shortness_of_breath_rest/flows/reassure_low_risk.yaml b/list/taxonomy/shortness_of_breath_rest/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9668527e34ba94ff2edf9649836c954601eec721
--- /dev/null
+++ b/list/taxonomy/shortness_of_breath_rest/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: shortness_of_breath_rest
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: sob_rest_reassure
+      goal: "Acknowledge the patient's concern about breathing, note that their care team will be informed for routine follow-up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/shortness_of_breath_rest/flows/safety_screen.yaml b/list/taxonomy/shortness_of_breath_rest/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..87c91bdc08d1b3a3a88396412793b0f99a9432bf
--- /dev/null
+++ b/list/taxonomy/shortness_of_breath_rest/flows/safety_screen.yaml
@@ -0,0 +1,54 @@
+flow_id: safety_screen
+type: screening
+domain: shortness_of_breath_rest
+
+required_slots:
+  - sob_at_rest
+  - sob_onset
+  - exertion_context
+  - breathing_effort
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: sob_rest_screen_step1
+      goal: "Determine whether shortness of breath occurs at rest or only with exertion"
+      tone: calm_urgent
+      must_include:
+        - "breathing"
+      must_ask:
+        - "Are you short of breath right now while sitting or lying still?"
+        - "When did the breathing difficulty start?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - sob_at_rest
+      - sob_onset
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: sob_rest_screen_step2
+      goal: "Screen for exertion-only versus rest-state breathing difficulty"
+      tone: calm_urgent
+      must_include:
+        - "understand"
+      must_ask:
+        - "Does the shortness of breath only happen when you're active or moving around?"
+        - "How hard is it to take a full breath right now?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - exertion_context
+      - breathing_effort
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_r3
diff --git a/list/taxonomy/shortness_of_breath_rest/rules.yaml b/list/taxonomy/shortness_of_breath_rest/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..91a2540bf120afbbd306d7c6af4e3ce27c919c4e
--- /dev/null
+++ b/list/taxonomy/shortness_of_breath_rest/rules.yaml
@@ -0,0 +1,27 @@
+domain: shortness_of_breath_rest
+target_risk_class: R3
+
+decision_rules:
+  - id: shortness_of_breath_rest_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: shortness_of_breath_rest_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: shortness_of_breath_rest_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: shortness_of_breath_rest_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
diff --git a/list/taxonomy/shortness_of_breath_rest/triggers.yaml b/list/taxonomy/shortness_of_breath_rest/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a3a67c94d87914adb4c8e4abc2b600412385c8b5
--- /dev/null
+++ b/list/taxonomy/shortness_of_breath_rest/triggers.yaml
@@ -0,0 +1,157 @@
+domain: shortness_of_breath_rest
+priority: 99
+
+lexical_signals:
+  high:
+    phrases:
+      - "can't breathe"
+      - "shortness of breath at rest"
+      - "breathing getting worse rapidly"
+      - "struggling to breathe"
+      - "can't catch my breath"
+      - "gasping for air"
+      - "suffocating"
+      - "oxygen level dropping"
+      - "severe shortness of breath"
+      - "short of breath just sitting"
+      - "short of breath at rest"
+      - "can't get a full breath"
+      - "winded just sitting here"
+      - "breathing is really hard"
+    regex:
+      - "can'?t\\s+(breathe|catch\\s+my\\s+breath|get\\s+(a\\s+)?full\\s+breath)"
+      - "short\\s+of\\s+breath"
+      - "(winded|breathless).{0,20}(sit|rest|still|nothing|just)"
+      - "(can'?t|hard\\s+to|difficult\\s+to|struggle\\s+to|unable\\s+to)\\s+(breathe|get\\s+air|get\\s+breath)"
+  medium:
+    phrases:
+      - "having trouble breathing"
+      - "breathing is hard"
+      - "winded sitting still"
+      - "labored breathing"
+      - "respiratory distress"
+      - "short of breath doing nothing"
+      - "breathing difficulty at rest"
+      - "hard to pull air in"
+      - "feel like I can't get enough air"
+      - "my breathing is off"
+      - "I'm kind of winded"
+      - "I'm a little winded"
+      - "harder to breathe"
+      # --- additional naturalistic ---
+      - "can't get comfortable breathing"
+      - "have to sit up to breathe"
+      - "woke up gasping"
+    regex:
+      - "(trouble|difficulty|problem).{0,15}breath"
+      - "breath.{0,15}(hard|difficult|labored|shallow|rapid)"
+      - "(winded|breathless|panting)"
+      - "hard.{0,10}(to\\s+)?breath"
+      - "pull\\s+air\\s+in"
+      - "get\\s+(enough\\s+)?air"
+  low:
+    partials:
+      - "breathless"
+      - "dyspnea"
+      - "out of breath"
+      - "short of breath"
+
+negation_handling:
+  patterns:
+    - "no breathing problems"
+    - "breathing is fine now"
+    - "shortness of breath resolved"
+    - "when i exercise"
+    - "when exercising"
+    - "when i walk"
+    - "when walking"
+    - "when i climb"
+    - "when climbing"
+    - "with exertion"
+    - "during exercise"
+    - "during exertion"
+    - "while exercising"
+    - "with activity"
+    - "during activity"
+    - "when i'm active"
+    - "on exertion"
+    - "with physical"
+    - "after exercise"
+    - "after walking"
+    - "after climbing"
+    - "after exertion"
+    - "when i run"
+    - "when running"
+    - "with effort"
+    - "going up stairs"
+    - "going upstairs"
+    - "up stairs"
+    - "up the stairs"
+    - "climbing stairs"
+    - "flight of stairs"
+    - "flights of stairs"
+    - "push myself"
+    - "if i push"
+    - "hills"
+    - "uphill"
+    - "when i move"
+    - "when moving"
+    - "only when"
+    - "just when"
+    - "doing chores"
+    - "doing housework"
+    - "mowing"
+    - "vacuuming"
+    - "gardening"
+    - "working out"
+    - "on the treadmill"
+    - "on my walk"
+    - "during my walk"
+    - "after jogging"
+    - "when jogging"
+    - "during jogging"
+    - "after running"
+    - "while running"
+    - "after a jog"
+    - "after a run"
+    - "when i jog"
+    - "with walking"
+    - "with climbing"
+    - "with exercise"
+    - "with stairs"
+    - "after a hike"
+    - "when hiking"
+    - "during physical activity"
+    - "only with activity"
+    - "only during exercise"
+    - "only when walking"
+    - "only when i exert"
+    - "after physical exertion"
+    # --- R1 screening denial coverage ---
+    - "no shortness of breath"
+    - "not short of breath"
+    - "no breathing problems"
+    - "no trouble breathing"
+    - "breathing fine"
+    - "breathing is fine"
+    - "breathing is okay"
+    - "no difficulty breathing"
+    - "can breathe fine"
+    - "breathing normally"
+    - "not winded at rest"
+    - "not breathless"
+    - "I can breathe okay"
+    - "no breathing issues"
+    - "lungs feel fine"
+    # --- historical / administrative context (FDA-safe) ---
+    - "years ago"
+    - "in the past"
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+    - "appointment timing"
+  # Changed to 'suppress' for R1 false escalation reduction.
+  # Activity-based patterns and administrative context should suppress the domain.
+  action: downgrade_confidence
diff --git a/list/taxonomy/social_isolation/flows/clarify.yaml b/list/taxonomy/social_isolation/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c3850d2bed9bf355464d9b09813be61297352c12
--- /dev/null
+++ b/list/taxonomy/social_isolation/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: social_isolation
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: social_isolation_clarify
+      goal: "Ask patient to describe their home situation and any challenges they face with getting help"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "burden"
+      max_questions: 1
+    collects:
+      - social_isolation_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: resource_referral
diff --git a/list/taxonomy/social_isolation/flows/concern_assessment.yaml b/list/taxonomy/social_isolation/flows/concern_assessment.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3f86c94700debdfba9e32e889f449fef6a6fdce1
--- /dev/null
+++ b/list/taxonomy/social_isolation/flows/concern_assessment.yaml
@@ -0,0 +1,52 @@
+flow_id: concern_assessment
+type: assessment
+domain: social_isolation
+
+required_slots:
+  - living_situation
+  - support_network
+  - transportation_access
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: social_isolation_assess_step1
+      goal: "Understand the patient's living situation and whether they have people who help or check on them"
+      tone: warm_empathetic
+      must_include:
+        - "understand"
+      must_ask:
+        - "Can you tell me about your living situation? Do you live alone or with someone?"
+        - "Do you have family or friends who check in on you regularly?"
+      must_not:
+        - "burden"
+        - "sad"
+        - "depressed"
+      max_questions: 2
+    collects:
+      - living_situation
+      - support_network
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: social_isolation_assess_step2
+      goal: "Assess transportation and ability to access medical care and daily necessities"
+      tone: warm_empathetic
+      must_include:
+        - "appointments"
+      must_ask:
+        - "Are you able to get to your medical appointments and the pharmacy when you need to?"
+      must_not:
+        - "burden"
+        - "helpless"
+      max_questions: 1
+    collects:
+      - transportation_access
+
+exit:
+  on_complete: evaluate_concern
+  on_concern: resource_referral
+  on_low_risk: resource_referral
+  on_unclear: resource_referral
diff --git a/list/taxonomy/social_isolation/flows/resource_referral.yaml b/list/taxonomy/social_isolation/flows/resource_referral.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ca39c5287ec3a8c4e7fc380afc32b983139793e3
--- /dev/null
+++ b/list/taxonomy/social_isolation/flows/resource_referral.yaml
@@ -0,0 +1,23 @@
+flow_id: resource_referral
+type: resolution
+domain: social_isolation
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: social_isolation_resource_referral
+      goal: "Inform the patient that their care team will connect them with community resources for transportation, social support, and daily assistance"
+      tone: warm_empathetic
+      must_include:
+        - "care team"
+        - "resources"
+        - "support"
+      must_not:
+        - "burden"
+        - "helpless"
+        - "charity"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/social_isolation/rules.yaml b/list/taxonomy/social_isolation/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..964263c8ee02f4b10ffb50fd65eee4b927e3c720
--- /dev/null
+++ b/list/taxonomy/social_isolation/rules.yaml
@@ -0,0 +1,27 @@
+domain: social_isolation
+target_risk_class: R1
+
+decision_rules:
+  - id: social_isolation_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: concern_assessment
+
+  - id: social_isolation_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: concern_assessment
+
+  - id: social_isolation_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: social_isolation_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: resource_referral
diff --git a/list/taxonomy/social_isolation/triggers.yaml b/list/taxonomy/social_isolation/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6e20b11ce8d6e650f4e205e9bdee89547d30c408
--- /dev/null
+++ b/list/taxonomy/social_isolation/triggers.yaml
@@ -0,0 +1,73 @@
+domain: social_isolation
+priority: 30
+
+lexical_signals:
+  high:
+    phrases:
+      - "living alone and can't get help"
+      - "no one to talk to"
+      - "completely isolated"
+      - "can't get to my appointments"
+      - "no family nearby and I'm struggling"
+      - "no one checks on me"
+      - "all alone and can't manage"
+      - "have nobody to help me"
+      - "no transportation to the doctor"
+      - "can't get my groceries"
+      - "haven't talked to anyone in weeks"
+      - "no support at all"
+      - "alone and can't take care of myself"
+      - "no one to drive me"
+      - "stuck at home with no help"
+    regex:
+      - "(no\\s+one|nobody|don't\\s+have\\s+anyone).{0,20}(help|talk|check|visit|drive|take\\s+me)"
+      - "(can't|cannot|unable\\s+to)\\s+get\\s+to.{0,15}(appointment|doctor|pharmacy|store|hospital)"
+      - "(completely|totally|very|extremely).{0,10}(isolated|alone|lonely)"
+      - "(no|don't\\s+have).{0,10}(family|friends|support|help).{0,10}(nearby|close|around|available)"
+  medium:
+    phrases:
+      - "living alone"
+      - "lonely"
+      - "isolated"
+      - "no family nearby"
+      - "hard to get to appointments"
+      - "don't have transportation"
+      - "no one around"
+      - "by myself most of the time"
+      - "don't see people much"
+      - "no visitors"
+      - "can't get out much"
+      - "stuck at home"
+      - "no rides"
+    regex:
+      - "(living|live)\\s+(alone|by\\s+myself)"
+      - "(no|don't\\s+have|lack).{0,10}(transportation|rides|way\\s+to\\s+get)"
+      - "(lonely|lonesome|isolated).{0,10}(lately|recently|always|often)"
+  low:
+    partials:
+      - "alone"
+      - "lonely"
+      - "isolated"
+      - "no rides"
+      - "transportation"
+
+negation_handling:
+  patterns:
+    - "not lonely"
+    - "have plenty of support"
+    - "family visits often"
+    - "not isolated"
+    - "have people around"
+    - "good support system"
+    - "have family nearby"
+    - "my family is nearby"
+    - "friends check on me"
+    - "i have transportation"
+    - "got transportation"
+    - "can get to appointments"
+    - "son drives me"
+    - "daughter helps me"
+    - "neighbor takes me"
+    - "have a ride"
+    - "not alone"
+  action: downgrade_confidence
diff --git a/list/taxonomy/stroke_symptoms/flows/clarify.yaml b/list/taxonomy/stroke_symptoms/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e2fe593da1ed3de34dc74d81161d9086da793c2c
--- /dev/null
+++ b/list/taxonomy/stroke_symptoms/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: stroke_symptoms
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: stroke_symptoms_clarify
+      goal: "Ask patient to describe their stroke symptoms symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - stroke_symptoms_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/stroke_symptoms/flows/escalate_r3.yaml b/list/taxonomy/stroke_symptoms/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4145e06cf0bfe9123285e6f0c0a816e1f46a9d6c
--- /dev/null
+++ b/list/taxonomy/stroke_symptoms/flows/escalate_r3.yaml
@@ -0,0 +1,38 @@
+flow_id: escalate_r3
+type: escalation
+domain: stroke_symptoms
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Inform patient this requires immediate clinical attention and they will
+      be transferred
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/stroke_symptoms/flows/handoff.yaml b/list/taxonomy/stroke_symptoms/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..beb67c75886ba645ae72e6d7e753fcca64ff897f
--- /dev/null
+++ b/list/taxonomy/stroke_symptoms/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: stroke_symptoms
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: stroke_symptoms_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: stroke_symptoms_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/stroke_symptoms/flows/reassure_low_risk.yaml b/list/taxonomy/stroke_symptoms/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..215ad38fba0db0ae0fef1c4f28fe80bb63c15320
--- /dev/null
+++ b/list/taxonomy/stroke_symptoms/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: stroke_symptoms
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: stroke_symptoms_reassure
+      goal: "Acknowledge the patient's concern about neurological symptoms, note that their care team will be informed for routine follow-up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/stroke_symptoms/flows/safety_screen.yaml b/list/taxonomy/stroke_symptoms/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..43755e9dc779ecd2a4259bfc25483244aa63b83d
--- /dev/null
+++ b/list/taxonomy/stroke_symptoms/flows/safety_screen.yaml
@@ -0,0 +1,75 @@
+flow_id: safety_screen
+type: screening
+domain: stroke_symptoms
+
+required_slots:
+  - balance_deficit
+  - vision_change
+  - facial_droop
+  - arm_weakness
+  - speech_slurring
+  - symptom_onset_time
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: stroke_screen_befast
+      goal: "Screen for BE-FAST balance and eye symptoms"
+      tone: calm_urgent
+      must_include:
+        - "important"
+      must_ask:
+        - "Are you having any trouble with balance or coordination?"
+        - "Have you noticed any sudden changes in your vision?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - balance_deficit
+      - vision_change
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: stroke_screen_step1
+      goal: "Screen for classic FAST stroke indicators"
+      tone: calm_urgent
+      must_include:
+        - "important"
+      must_ask:
+        - "Is one side of your face drooping or feeling numb?"
+        - "Can you raise both arms — is one arm weak or drifting down?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - facial_droop
+      - arm_weakness
+
+  - step: 3
+    type: ask
+    response_spec:
+      id: stroke_screen_step2
+      goal: "Screen for speech changes and determine timing"
+      tone: calm_urgent
+      must_include:
+        - "need to know"
+      must_ask:
+        - "Is your speech slurred or are you having trouble getting words out?"
+        - "When did these symptoms start?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - speech_slurring
+      - symptom_onset_time
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_r3
diff --git a/list/taxonomy/stroke_symptoms/rules.yaml b/list/taxonomy/stroke_symptoms/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4da9ce04d90d47418432b8f6184f51cf808dd3ae
--- /dev/null
+++ b/list/taxonomy/stroke_symptoms/rules.yaml
@@ -0,0 +1,27 @@
+domain: stroke_symptoms
+target_risk_class: R3
+
+decision_rules:
+  - id: stroke_symptoms_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: stroke_symptoms_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: stroke_symptoms_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: stroke_symptoms_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
diff --git a/list/taxonomy/stroke_symptoms/triggers.yaml b/list/taxonomy/stroke_symptoms/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..28d1100af0311ab55bff9fff42ae1e8ba085ab5f
--- /dev/null
+++ b/list/taxonomy/stroke_symptoms/triggers.yaml
@@ -0,0 +1,163 @@
+domain: stroke_symptoms
+priority: 98
+
+lexical_signals:
+  high:
+    phrases:
+      - "face is drooping"
+      - "can't move my arm"
+      - "slurred speech"
+      - "stroke"
+      - "one side of my body is weak"
+      - "sudden numbness on one side"
+      - "can't speak clearly"
+      - "facial droop"
+      - "one side of my face"
+      - "arm isn't working"
+      - "can't lift my arm"
+    regex:
+      - "(face|facial).{0,12}(droop|numb|sag|weak|lopsid)"
+      - "slurred\\s+speech"
+      - "(can'?t|unable\\s+to|couldn'?t)\\s+(move|lift|feel|use)\\s+(my\\s+)?(arm|hand|leg|side)"
+      - "(arm|hand|leg|side).{0,15}(isn'?t|not|won'?t|can'?t).{0,10}(work|cooperat|mov|respond)"
+      - "(one|left|right)\\s+side.{0,15}(weak|numb|heavy|dead|not working|tingl)"
+      - "sudden.{0,10}(numb|weak|tingl).{0,15}(one side|left|right|arm|leg|face)"
+  medium:
+    phrases:
+      - "face feels numb"
+      - "arm is tingling on one side"
+      - "words coming out wrong"
+      - "sudden confusion"
+      - "trouble speaking suddenly"
+      - "vision loss in one eye"
+      - "sudden weakness one side"
+      - "hand isn't cooperating"
+      - "words aren't coming out right"
+      - "speech sounds funny"
+      - "trouble with words"
+      - "hand feels like it's not mine"
+      - "arm feels heavy and won't work"
+      - "words are coming out wrong"
+      - "words are coming out weird"
+      - "words coming out garbled"
+      - "words coming out thick"
+      - "face feels droopy"
+      - "tongue feels thick"
+      - "tongue is heavy"
+      - "tongue was clumsy"
+      - "hand felt like it wasn't mine"
+      - "arm felt like it wasn't mine"
+      - "not making sense"
+      - "not making much sense"
+      - "talking kind of funny"
+      - "words were thick"
+      - "words feel mushy"
+      - "words didn't match"
+      - "words didn't match what I was thinking"
+      - "talking feels sticky"
+      - "keep losing the word I want"
+      - "hand keeps letting go of things"
+      - "keep dropping things"
+      - "left side feels tingly"
+      # --- MINIMIZER coverage ---
+      - "feeling a bit off"
+      - "body's lagging"
+      - "bumped into the doorway"
+      - "lip feels sort of tingly"
+      - "words feel stuck"
+      - "face looks different"
+      - "body isn't cooperating"
+      - "legs feel kind of funny"
+    regex:
+      - "(word|speech|speak|talk).{0,30}(wrong|funny|garbled|slur|trouble|off|weird|jumbled|thick|mushy|sticky|match)"
+      - "(hand|arm|leg|foot).{0,25}(not mine|foreign|dead|heavy|weird|numb|tingle|clumsy|wasn.t mine)"
+      - "(trouble|difficulty|problem).{0,10}(speak|talk|word|typing|writing)"
+      - "(hand|arm).{0,15}(letting\\s+go|keeps?\\s+dropping|won't\\s+hold|can't\\s+grip)"
+      - "(losing|lost|can't\\s+find).{0,15}(the\\s+)?word"
+      - "talk.{0,10}feels?.{0,10}(sticky|thick|weird|wrong|off)"
+      - "words?.{0,10}(didn't|don't|did\\s+not).{0,10}(match|come\\s+out)"
+      - "(sudden|all of a sudden|out of nowhere).{0,20}(confus|dizzy|weak|numb)"
+      - "words?.{0,10}coming out.{0,10}(wrong|weird|garbled|thick|funny|mushy|slurred|jumbled)"
+      - "(tongue|mouth).{0,10}(thick|heavy|clumsy|numb|swollen|fat|not working)"
+      - "(not|isn.t|can.t).{0,8}making.{0,6}(much\\s+)?sense"
+      - "words?.{0,10}(feel|felt|sound).{0,10}(mushy|thick|heavy|slurred|garbled|wrong|off)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(body|side).{0,15}(lagging|not cooperating|not responding|feels? off|'s off|is off|seems? off|weird|sluggish)"
+      - "(stumbl|trip|bump).{0,20}(couple|few|times|morning|today|things|doorway|wall|counter)"
+      - "(clumsy|fumbl|clunky|uncoordinated).{0,15}(today|hand|arm|suddenly|this morning|all of a sudden)"
+      - "(tingly|tingling|numb|weird).{0,15}(lip|cheek|face|mouth|chin|jaw)"
+      - "(trouble|having trouble)\\s+organizing.{0,10}(thought|word|sentence)"
+      - "(arm|hand|leg).{0,15}(heavier|not right|shaky|sinking|weaker|not quite right)"
+      - "marbles\\s+in\\s+(my|his|her)\\s+mouth"
+      - "(vision|things|everything).{0,15}(blurry|smeared|off|funny|weird).{0,15}(on|one|left|right|the)\\s+(side|eye)"
+      - "(arm|hand|leg).{0,15}(a bit|kind of|sort of|little).{0,15}(weak|numb|heavy|tingly|off|shaky)"
+  low:
+    partials:
+      - "hemiparesis"
+      - "aphasia"
+      - "dysarthria"
+      - "TIA"
+      - "one side is weak"
+      - "drooping face"
+      - "slurred"
+
+negation_handling:
+  patterns:
+    - "no stroke symptoms"
+    - "face is fine"
+    - "speech is normal"
+    - "no numbness"
+    # --- R1 denial coverage ---
+    - "no facial droop"
+    - "no drooping"
+    - "face looks normal"
+    - "face is symmetrical"
+    - "no slurring"
+    - "not slurring"
+    - "no trouble speaking"
+    - "no arm weakness"
+    - "no weakness on one side"
+    - "arms and legs are fine"
+    - "no confusion"
+    - "not confused"
+    - "not dizzy"
+    - "no dizziness"
+    - "no vision problems"
+    # --- progressive_weakness (R1) chronic/gradual context ---
+    - "gradually getting weaker"
+    - "been getting weaker"
+    - "been weak since"
+    - "weakness for weeks"
+    - "weakness for months"
+    - "chronic weakness"
+    - "chronic fatigue"
+    - "fatigue and weakness"
+    - "since my surgery"
+    - "since I got home"
+    - "since discharge"
+    - "since the procedure"
+    - "physical therapy"
+    - "PT appointment"
+    - "rehab"
+    - "recovering from surgery"
+    - "recovery has been"
+    - "energy levels"
+    - "deconditioning"
+    - "not as strong as before"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_has_condition: ["I48.*"]
+      reason: "Afib is leading cause of cardioembolic stroke"
+    - when:
+        patient_has_condition: ["I63.*"]
+      reason: "Prior stroke history increases recurrence risk"
diff --git a/list/taxonomy/substance_use_crisis/flows/clarify.yaml b/list/taxonomy/substance_use_crisis/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..07d8297364cce909a4f34f85427b0fcb4b46e188
--- /dev/null
+++ b/list/taxonomy/substance_use_crisis/flows/clarify.yaml
@@ -0,0 +1,26 @@
+flow_id: clarify
+type: clarification
+domain: substance_use_crisis
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: substance_crisis_clarify
+      goal: "Gently ask patient to describe their situation"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "I want to make sure I understand what you're going through. Could you tell me a bit more?"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "addict"
+      max_questions: 1
+    collects:
+      - substance_crisis_clarify_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: escalate_r2
diff --git a/list/taxonomy/substance_use_crisis/flows/escalate_r2.yaml b/list/taxonomy/substance_use_crisis/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3762525c16643790335fd7bfafc985d78d20260c
--- /dev/null
+++ b/list/taxonomy/substance_use_crisis/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: substance_use_crisis
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: substance_crisis_r2_escalation_notice
+      goal: "Connect patient with substance use counselor or crisis services"
+      tone: empathetic
+      must_include:
+        - "support"
+        - "SAMHSA"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "addict"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: substance_use_counselor
+    urgency: same_day
+    response_spec:
+      id: substance_crisis_r2_handoff
+      goal: "Transfer to substance use counselor"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not:
+        - "goodbye"
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/substance_use_crisis/flows/escalate_r3.yaml b/list/taxonomy/substance_use_crisis/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a75c9828b8957eb1b58ab577c8e9105af350b0d1
--- /dev/null
+++ b/list/taxonomy/substance_use_crisis/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: substance_use_crisis
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: substance_crisis_r3_escalation_notice
+    goal: Life-threatening withdrawal — immediate medical attention
+    tone: calm_urgent
+    must_include:
+    - call 911
+    - right away
+    - medical
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: substance_crisis_r3_handoff
+    goal: Transfer to clinical nurse for medical emergency
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/substance_use_crisis/flows/safety_screen.yaml b/list/taxonomy/substance_use_crisis/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a8117b5eaaeeb95fc558ead65133787e7d254574
--- /dev/null
+++ b/list/taxonomy/substance_use_crisis/flows/safety_screen.yaml
@@ -0,0 +1,75 @@
+flow_id: safety_screen
+type: screening
+domain: substance_use_crisis
+
+required_slots:
+  - substance_type
+  - crisis_type
+  - withdrawal_severity
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: substance_crisis_screen_step1
+      goal: "Determine substance involved and type of crisis (withdrawal vs relapse vs intoxication)"
+      tone: gentle_professional
+      must_include:
+        - "understand"
+        - "help"
+      must_ask:
+        - "Can you tell me what substance is involved?"
+        - "Are you going through withdrawal, or have you recently used?"
+      must_not:
+        - "don't worry"
+        - "diagnos"
+        - "addict"
+      max_questions: 2
+    collects:
+      - substance_type
+      - crisis_type
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: substance_crisis_screen_step2
+      goal: "Assess withdrawal severity and consciousness"
+      tone: gentle_professional
+      must_include:
+        - "important"
+      must_ask:
+        - "How severe are your symptoms right now — are you able to think clearly?"
+        - "Have you had any seizures, or are you seeing or hearing things that aren't there?"
+      must_not:
+        - "don't worry"
+        - "diagnos"
+      max_questions: 2
+    collects:
+      - withdrawal_severity
+      - consciousness_status
+
+  - step: 3
+    type: ask
+    response_spec:
+      id: substance_crisis_screen_step3
+      goal: "Check seizure history and timing of last use"
+      tone: gentle_professional
+      must_include:
+        - "understand"
+      must_ask:
+        - "Have you ever had a seizure during withdrawal before?"
+        - "When was the last time you used or had a drink?"
+      must_not:
+        - "don't worry"
+        - "diagnos"
+      max_questions: 2
+    collects:
+      - seizure_history
+      - last_use_timing
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_r2: escalate_r2
+  on_low_risk: escalate_r2
+  on_unclear: escalate_r2
diff --git a/list/taxonomy/substance_use_crisis/rules.yaml b/list/taxonomy/substance_use_crisis/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c7bf63791021caeaf6baeb4e6bcd4439a52ed3aa
--- /dev/null
+++ b/list/taxonomy/substance_use_crisis/rules.yaml
@@ -0,0 +1,33 @@
+domain: substance_use_crisis
+target_risk_class: R2
+
+decision_rules:
+  - id: substance_crisis_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: substance_crisis_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: substance_crisis_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: substance_crisis_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: substance_crisis_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/substance_use_crisis/triggers.yaml b/list/taxonomy/substance_use_crisis/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4cf8ce4a665499c5b404e017bf52cc6822a18a75
--- /dev/null
+++ b/list/taxonomy/substance_use_crisis/triggers.yaml
@@ -0,0 +1,69 @@
+domain: substance_use_crisis
+priority: 70
+
+lexical_signals:
+  high:
+    phrases:
+      - "seizure from withdrawal"
+      - "DTs"
+      - "delirium tremens"
+      - "seeing things since I stopped drinking"
+      - "shaking and sweating"
+      - "withdrawal seizure"
+      - "alcohol withdrawal hallucinations"
+      - "benzo withdrawal seizure"
+      - "stopped drinking and I'm shaking"
+      - "tremors from not drinking"
+      - "I think I'm going through DTs"
+    regex:
+      - "(seizure|convuls)\\s+(from|during|because|due to)\\s+(withdrawal|quitting|stopping)"
+      - "(DTs?|delirium\\s+tremens)"
+      - "(see|seeing|hear|hearing)\\s+(things|voices|bugs|spiders).{0,20}(stop|quit|withdrawal|not drinking|sober)"
+      - "(shak|tremor|trembl).{0,15}(sweat|fever|nausea|vomit)"
+  medium:
+    phrases:
+      - "haven't had a drink in days and I'm shaking"
+      - "started using again"
+      - "relapsed"
+      - "I fell off the wagon"
+      - "started drinking again"
+      - "using again after being clean"
+      - "can't stop shaking"
+      - "withdrawal symptoms"
+      - "detox at home"
+      - "trying to quit cold turkey"
+      - "ran out of my suboxone"
+      - "ran out of my methadone"
+      - "sweating and can't sleep since I stopped"
+      - "heart racing since I stopped drinking"
+    regex:
+      - "(haven'?t|stopped|quit).{0,20}(drink|drug|use|using).{0,20}(shak|sweat|sick|nausea|tremor|vomit)"
+      - "(start|started|been)\\s+(using|drinking|taking)\\s+(again|back)"
+      - "(relaps|fell off|slip|slipped)"
+      - "(withdrawal|detox).{0,15}(symptom|home|myself|alone|cold turkey)"
+      - "(ran out|can'?t get|no more)\\s+(of\\s+)?(suboxone|methadone|subutex|buprenorphine|naltrexone)"
+      - "(heart|pulse)\\s+(racing|fast|pounding).{0,20}(stop|quit|withdrawal)"
+  low:
+    partials:
+      - "withdrawal"
+      - "relapse"
+      - "shaking"
+      - "detox"
+      - "cold turkey"
+      - "using again"
+
+negation_handling:
+  patterns:
+    - "sober for years"
+    - "clean and sober"
+    - "in recovery and doing well"
+    - "been clean for"
+    - "haven't used in"
+    - "sober anniversary"
+    - "recovery is going well"
+    - "my withdrawal was years ago"
+    - "completed detox"
+    - "graduated from treatment"
+    - "shaking from cold weather"
+    - "shaking from anxiety"
+  action: downgrade_confidence
diff --git a/list/taxonomy/sudden_vision_loss/flows/clarify.yaml b/list/taxonomy/sudden_vision_loss/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9fb2a948cb486323ac12dd30563e7fc7ea94b343
--- /dev/null
+++ b/list/taxonomy/sudden_vision_loss/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: sudden_vision_loss
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: sudden_vision_loss_clarify
+      goal: "Ask patient to describe their sudden vision loss symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - sudden_vision_loss_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/sudden_vision_loss/flows/escalate_r3.yaml b/list/taxonomy/sudden_vision_loss/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..fc51accfef8525ea93757bb3fcf033d2e69d204d
--- /dev/null
+++ b/list/taxonomy/sudden_vision_loss/flows/escalate_r3.yaml
@@ -0,0 +1,38 @@
+flow_id: escalate_r3
+type: escalation
+domain: sudden_vision_loss
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Inform patient this requires immediate clinical attention and they will
+      be transferred
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/sudden_vision_loss/flows/handoff.yaml b/list/taxonomy/sudden_vision_loss/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3e2d1bc558e455ec5fa51a3e2bb1c3bd90308510
--- /dev/null
+++ b/list/taxonomy/sudden_vision_loss/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: sudden_vision_loss
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: sudden_vision_loss_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: sudden_vision_loss_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/sudden_vision_loss/rules.yaml b/list/taxonomy/sudden_vision_loss/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e491daa5e1ca61e6dc6a9739f18f2793c24d7991
--- /dev/null
+++ b/list/taxonomy/sudden_vision_loss/rules.yaml
@@ -0,0 +1,21 @@
+domain: sudden_vision_loss
+target_risk_class: R3
+
+decision_rules:
+  - id: sudden_vision_loss_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r3
+
+  - id: sudden_vision_loss_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r3
+
+  - id: sudden_vision_loss_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/sudden_vision_loss/triggers.yaml b/list/taxonomy/sudden_vision_loss/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..337c2badaf87889d141bed35b6129c156c5bd29c
--- /dev/null
+++ b/list/taxonomy/sudden_vision_loss/triggers.yaml
@@ -0,0 +1,172 @@
+domain: sudden_vision_loss
+priority: 84
+
+lexical_signals:
+  high:
+    phrases:
+      - "suddenly can't see"
+      - "lost vision in one eye"
+      - "went blind suddenly"
+      - "vision gone"
+      - "sudden vision loss"
+      - "can't see anything suddenly"
+      - "eye just went dark"
+      - "can't see out of my eye"
+      - "vision went black"
+      - "eye went blind"
+    regex:
+      - "sudden(ly)?\\s+(can'?t\\s+see|couldn'?t\\s+see|vision\\s+loss|blind|blurr)"
+      - "eye.{0,20}(went|turned|got).{0,15}(dark|black|blind|blank|dim)"
+      - "(can'?t|couldn'?t)\\s+see.{0,20}(out of|with|from).{0,10}eye"
+      - "vision.{0,15}(went|dropped|disappeared|gone|lost|dark)"
+      - "(left|right)\\s+eye.{0,20}(dark|blind|can'?t see|blurr|dim)"
+      # --- reversed word order + caregiver ---
+      - "lost\\s+vision\\s+(in|from|completely)"
+      - "(couldn'?t|can'?t)\\s+see\\s+(anything|out of|part|much)\\s+(out of\\s+)?(that|his|her|my|the)\\s+(eye|right|left)"
+      - "(he|she|my|father|mother|dad|mom).{0,30}lost\\s+vision"
+      - "(went|gone)\\s+(completely\\s+)?(black|dark|blind)\\s+(in\\s+)?(my|his|her|that|one|the)\\s+(eye|right|left)"
+  medium:
+    phrases:
+      - "vision suddenly blurry"
+      - "seeing dark spots suddenly"
+      - "part of vision missing"
+      - "curtain over my eye"
+      - "sudden blurring of vision"
+      - "lost peripheral vision"
+      - "like a curtain dropped"
+      - "eye acting weird"
+      - "vision got smeary"
+      - "everything looks dim"
+      - "shadow in my vision"
+      - "blind spot appeared"
+      - "gray haze"
+      - "washed out vision"
+      - "lower half looked washed out"
+      - "eye went dim"
+      # --- MINIMIZER coverage ---
+      - "vision's been a little funny"
+      - "things looked a bit off"
+      - "everything's kind of fuzzy"
+      - "can't see the words properly"
+      - "dark area in my vision"
+      - "letters went gray"
+      - "vision seems a bit off"
+      - "eye isn't working right"
+      - "can barely see out of it"
+      - "part of my view is gone"
+      - "like someone turned off the lights on that side"
+      - "not seeing right"
+      # --- additional patterns ---
+      - "everything looks washed out"
+      - "colors aren't right"
+      - "things look faded"
+      - "vision went dark then cleared"
+      - "tons of floaters suddenly"
+      - "lots of flashes"
+      - "covering one eye makes it"
+      # --- complete loss phrases ---
+      - "can't see out of one eye"
+      - "can't see out of my left eye"
+      - "can't see out of my right eye"
+      - "vision just went black"
+      - "eye went completely dark"
+      - "lost sight in one eye"
+      - "one eye just stopped working"
+      # --- partial loss phrases ---
+      - "half my vision is gone"
+      - "half my vision disappeared"
+      - "blind spot just appeared"
+      - "dark spot in my vision"
+      - "part of my vision is missing"
+      - "missing a chunk of my vision"
+      - "hole in my vision"
+      - "side of my vision is dark"
+      # --- transient patterns ---
+      - "vision came back but I'm worried"
+      - "sight went dark then cleared"
+      - "went blind for a minute then it came back"
+      - "vision went out but returned"
+      - "temporary blindness in one eye"
+      # --- floaters and flashes ---
+      - "floaters and then vision loss"
+      - "flashes and now can't see"
+      - "seeing flashes and losing vision"
+      - "floaters everywhere and vision going"
+      - "shower of floaters"
+      - "suddenly lots of floaters"
+    regex:
+      - "curtain.{0,15}(eye|vision|dropped|fell)"
+      - "eye.{0,20}(weird|strange|off|funny|acting)"
+      - "vision.{0,15}(blurr|dim|smeary|foggy|cloudy|hazy)"
+      - "(floater|flash).{0,20}(eye|vision)"
+      - "(eye|vision).{0,20}(floater|flash)"
+      - "(gray|grey)\\s+(haze|curtain|film|veil)"
+      - "(half|part).{0,15}(washed|faded|dimmed|dark)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "vision.{0,20}(funny|off|weird|strange|different|not right|not quite)"
+      - "things.{0,15}(look|looked|seem|seemed).{0,15}(off|different|wrong|funny|weird|dim|gray|faded|blurry)"
+      - "(blurry|fuzzy|blurred|hazy|foggy).{0,20}(eye|vision|see|sight|everything)"
+      - "(shadow|dark).{0,15}(area|patch|spot|edge|side|creep|part)"
+      - "(can'?t|couldn'?t|trouble|hard).{0,15}(see|focus|read|make out).{0,15}(right|well|properly|clearly|words|screen)"
+      - "(eye|vision|sight).{0,15}(not right|acting up|playing tricks|went|going|isn'?t right)"
+      - "(screen|letters|words|text).{0,15}(faded|gray|blurry|fuzzy|dim|disappeared)"
+      - "(everything|things).{0,15}(fuzzy|blurry|gray|dim|dark|faded|hazy)"
+      - "can'?t\\s+(quite\\s+)?(see|focus|read|make).{0,15}(properly|right|well|clearly)"
+      # --- from missed scenarios analysis ---
+      - "(couldn'?t|can'?t)\\s+(see|make out).{0,20}(out of|with|from).{0,10}(my|his|her|the|that)"
+      - "(left|right)\\s+side\\s+(just\\s+)?went\\s+(dark|black|blank|dim)"
+      - "(went|gone)\\s+(completely\\s+)?(black|dark)\\s+(sometime|during|in|last)"
+      - "(words|text|letters|newspaper).{0,15}(weren'?t|just weren'?t|not)\\s+(there|visible|clear|readable)"
+      - "(part|half|side)\\s+(of\\s+)?(what I|my vision|my view|my sight).{0,15}(missing|gone|dark|black|blank)"
+      - "(blurriness|blurry|can'?t see).{0,15}(in|from|with)\\s+(my|his|her)\\s+(right|left)\\s+eye"
+      # --- painless vision loss (retinal) ---
+      - "(painless|no pain)\\s+(but\\s+)?(can'?t see|vision|blind|lost sight)"
+      # --- transient (amaurosis fugax) ---
+      - "(vision|sight|seeing)\\s+(came back|cleared|returned)\\s+(but|then|and)"
+      # --- sudden floaters/flashes ---
+      - "(tons?|lots?|sudden|many|bunch)\\s+(of\\s+)?(floaters|flashes)"
+      # --- complete loss patterns ---
+      - "(can'?t|couldn'?t)\\s+see\\s+(out\\s+of\\s+)?(one|my|this|that|left|right)\\s+eye"
+      - "(vision|sight)\\s+(just\\s+)?(went|gone|disappeared|vanished)\\s+(black|dark|completely)"
+      - "(everything|world)\\s+(went|gone|turned)\\s+(black|dark)\\s+(in|from|with)\\s+(one|my|this)\\s+eye"
+      # --- partial loss patterns ---
+      - "(half|part|portion|section)\\s+(of\\s+)?(my\\s+)?vision\\s+(is\\s+)?(gone|missing|dark|black|blank)"
+      - "(blind\\s+spot|dark\\s+spot|black\\s+spot)\\s+(appeared|showed\\s+up|just\\s+appeared|out\\s+of\\s+nowhere)"
+      - "(upper|lower|left|right)\\s+(half|part|side)\\s+(of\\s+)?vision\\s+(is\\s+)?(gone|dark|missing)"
+      - "(chunk|piece|area)\\s+(of\\s+)?(my\\s+)?vision\\s+(is\\s+)?(missing|gone|dark)"
+      # --- transient loss patterns ---
+      - "(vision|sight)\\s+(came\\s+back|returned|cleared)\\s+(but|after|then|and\\s+then)"
+      - "(went\\s+dark|blacked\\s+out|couldn'?t\\s+see).{0,20}(then|but).{0,15}(came\\s+back|cleared|returned)"
+      - "(temporary|briefly|for\\s+a\\s+(moment|minute|second|bit))\\s+(couldn'?t\\s+see|lost\\s+vision|went\\s+dark)"
+      # --- associated symptoms ---
+      - "(floaters|flashes).{0,15}(and|with|then).{0,15}(vision\\s+loss|can'?t\\s+see|dark|blind)"
+      - "(vision\\s+loss|can'?t\\s+see).{0,15}(and|with|plus).{0,15}(floaters|flashes)"
+      - "(flashing\\s+lights|light\\s+flashes).{0,15}(then|and|before).{0,15}(couldn'?t\\s+see|vision)"
+  low:
+    partials:
+      - "vision loss"
+      - "blind spot"
+      - "amaurosis"
+      - "can't see right"
+      - "eye is blurry"
+      - "seeing spots"
+      - "fuzzy vision"
+      - "blurry eye"
+
+negation_handling:
+  patterns:
+    - "vision is fine"
+    - "can see clearly"
+    - "no vision problems"
+    # --- R1 denial coverage ---
+    - "eyes are fine"
+    - "vision is normal"
+    - "no blurriness"
+    - "not blurry"
+    - "no blind spots"
+    - "no dark spots"
+    - "no vision changes"
+    - "vision hasn't changed"
+    - "no trouble seeing"
+    - "no eye problems"
+  action: downgrade_confidence
diff --git a/list/taxonomy/suicidal_ideation/flows/clarify.yaml b/list/taxonomy/suicidal_ideation/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..75e3270c08986229d262db405335eb30a1b5706d
--- /dev/null
+++ b/list/taxonomy/suicidal_ideation/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: suicidal_ideation
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: suicidal_ideation_clarify
+      goal: "Ask patient to describe their suicidal ideation symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - suicidal_ideation_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/suicidal_ideation/flows/escalate_r3.yaml b/list/taxonomy/suicidal_ideation/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..29d89a6a58d0a87a86adfb83d0780f11f1d294c2
--- /dev/null
+++ b/list/taxonomy/suicidal_ideation/flows/escalate_r3.yaml
@@ -0,0 +1,38 @@
+flow_id: escalate_r3
+type: escalation
+domain: suicidal_ideation
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Inform patient this requires immediate clinical attention and they will
+      be transferred
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/suicidal_ideation/flows/handoff.yaml b/list/taxonomy/suicidal_ideation/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..58092ba76ca2a9a9feb3cf20d97fa8cd9ce820c4
--- /dev/null
+++ b/list/taxonomy/suicidal_ideation/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: suicidal_ideation
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: suicidal_ideation_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: suicidal_ideation_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/suicidal_ideation/rules.yaml b/list/taxonomy/suicidal_ideation/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..9a2cfe20da5cdf8b099ac076146ab048311fb9a6
--- /dev/null
+++ b/list/taxonomy/suicidal_ideation/rules.yaml
@@ -0,0 +1,21 @@
+domain: suicidal_ideation
+target_risk_class: R3
+
+decision_rules:
+  - id: suicidal_ideation_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r3
+
+  - id: suicidal_ideation_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r3
+
+  - id: suicidal_ideation_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/suicidal_ideation/triggers.yaml b/list/taxonomy/suicidal_ideation/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..edf083a50820f283ca2d88d5ce0711b3c737503a
--- /dev/null
+++ b/list/taxonomy/suicidal_ideation/triggers.yaml
@@ -0,0 +1,191 @@
+domain: suicidal_ideation
+priority: 94
+
+lexical_signals:
+  high:
+    phrases:
+      - "want to kill myself"
+      - "suicidal thoughts"
+      - "thinking about ending my life"
+      - "don't want to be alive"
+      - "planning to hurt myself"
+      - "want to die"
+      - "going to end it"
+      - "shouldn't be here anymore"
+      - "don't want to be here anymore"
+      - "thinking about not being here"
+      - "don't wanna be here"
+      - "tired of being here"
+      - "won't have to worry about me"
+      # --- passive ideation phrases ---
+      - "wish I wouldn't wake up"
+      - "don't want to exist"
+      - "wish I could just not wake up"
+      - "go to sleep and not wake up"
+      - "not wake up tomorrow"
+      - "just not exist anymore"
+      # --- method contemplation phrases ---
+      - "staring at pills"
+      - "looking at the bridge"
+      - "have a plan"
+      - "I have a plan"
+      - "know exactly how"
+      - "lethal dosing"
+      - "researching methods"
+      - "looked up lethal"
+      # --- euphemistic language phrases ---
+      - "end the pain"
+      - "permanent solution"
+      - "make it stop permanently"
+      - "end it all"
+      - "end this suffering"
+      - "final solution"
+      - "only way out"
+      # --- burden statements phrases ---
+      - "everyone better off without me"
+      - "just a burden"
+      - "they'd be better without me"
+      - "life insurance would help them more"
+      - "dragging everyone down"
+      # --- hopelessness cluster phrases ---
+      - "no way out"
+      - "nothing matters anymore"
+      - "no point in going on"
+      - "no reason to go on"
+      - "can't see a future"
+      - "no future for me"
+    regex:
+      - "(want|going|plan)\\s+to\\s+(kill|end|hurt)\\s+(myself|my\\s+life|it\\s+all|it)"
+      - "(don'?t|do not)\\s+(want|deserve)\\s+to\\s+(be\\s+alive|live|be\\s+here|exist)"
+      - "(shouldn'?t|should not)\\s+be\\s+here"
+      - "(thinking|thought).{0,10}(about|of).{0,10}(not being here|ending|killing|dying|suicide)"
+      - "(better|easier).{0,20}(off|if).{0,30}(dead|gone|without me|wasn'?t|not here|didn'?t exist)"
+      - "(don'?t|do not|doesn'?t).{0,5}wanna?.{0,5}be\\s+here"
+      - "tired\\s+of\\s+being\\s+here"
+      - "won'?t\\s+have\\s+to\\s+worry"
+      - "what\\s+if\\s+I\\s+(just\\s+)?(wasn'?t|weren'?t|wasn't)\\s+here"
+      - "if\\s+I\\s+(just\\s+)?(stopped|didn'?t|wasn'?t|weren't)"
+      # --- passive ideation regex ---
+      - "(wish|hope|pray|want)\\s+(I\\s+)?(wouldn'?t|didn'?t|don'?t|could\\s+just\\s+not)\\s+(wake|exist|be\\s+here)"
+      - "(go|went)\\s+to\\s+sleep\\s+and\\s+(not|never)\\s+wake"
+      - "not\\s+wake\\s+up\\s+(tomorrow|again|ever)"
+      - "(just\\s+)?not\\s+exist\\s+(anymore|any\\s+more)"
+      # --- method contemplation regex ---
+      - "(staring|stared|looking)\\s+(at|into)\\s+(the\\s+)?(pill|bridge|gun|rope|knife|razor|edge|bottle|medication|balcony|ledge|tracks)"
+      - "(have|got|made)\\s+a\\s+(plan|method|way)"
+      - "(know|figured out|researched)\\s+(exactly\\s+)?how\\s+(I|to)"
+      - "(lethal|fatal)\\s+(dose|dosing|amount)"
+      - "(looked|looking|research)\\s+(up|into)\\s+(lethal|methods|ways\\s+to)"
+      # --- euphemistic language regex ---
+      - "(end|stop)\\s+(the|this|my)\\s+(pain|suffering|struggle|misery)"
+      - "(permanent|final)\\s+(solution|answer|escape|rest|relief)"
+      - "(only|no\\s+other)\\s+(way\\s+)?out"
+      - "end\\s+it\\s+all"
+      - "make\\s+it\\s+(all\\s+)?stop"
+      # --- burden statements regex ---
+      - "(everyone|they|family|my\\s+wife|my\\s+husband|my\\s+kids).{0,20}(better|easier).{0,20}(off|without)\\s+(me|I)"
+      - "(just|nothing\\s+but|only)\\s+a\\s+burden"
+      - "(dragging|bringing|weighing)\\s+(everyone|them|you|my\\s+family)\\s+down"
+      - "life\\s+insurance\\s+would\\s+(help|be\\s+worth)"
+      # --- hopelessness cluster regex ---
+      - "(no|not\\s+any|can'?t\\s+see\\s+a?)\\s+(way\\s+out|future|hope|point|reason)"
+      - "nothing\\s+(matters|will\\s+change|helps)"
+      - "no\\s+point\\s+(in|of|to)\\s+(going\\s+on|living|continuing|trying)"
+      - "no\\s+reason\\s+to\\s+(go\\s+on|live|keep|continue)"
+      - "can'?t\\s+see\\s+(a\\s+)?(future|way\\s+(forward|out)|light)"
+  medium:
+    phrases:
+      - "feel like giving up"
+      - "life isn't worth living"
+      - "thinking about suicide"
+      - "wish I could just disappear"
+      - "better off without me"
+      - "no reason to go on"
+      - "everything would be easier if I wasn't here"
+      - "can't do this anymore"
+      - "don't see the point"
+      - "I just want it to stop"
+      - "I keep thinking I shouldn't be here"
+      - "I said some dumb stuff about not wanting to be around"
+      - "what if I just didn't have to deal"
+      - "just stopped existing"
+      - "if I didn't wake up"
+      # --- indirect / euphemistic ---
+      - "easier if I just"
+      - "you know what I mean"
+      - "not one of those people but"
+      - "wrote letters"
+      - "tying up loose ends"
+      - "everyone would be better"
+      - "just a burden"
+      - "sleep forever"
+      - "want the pain to stop permanently"
+      - "giving away my things"
+      - "said goodbye to everyone"
+      - "making arrangements"
+      - "put my affairs in order"
+      - "no point in fighting anymore"
+      - "I'm done"
+      - "what's the point"
+    regex:
+      - "(give|giving)\\s+up"
+      - "(no|don'?t\\s+see\\s+a?)\\s+(reason|point|purpose).{0,10}(to|for|in).{0,10}(go on|living|life)"
+      - "(wish|want).{0,15}(disappear|vanish|gone|not exist|not be here|not wake)"
+      - "(can'?t|cannot)\\s+(do|take|handle).{0,10}(this|it|anymore|any more)"
+      - "not\\s+want.{0,15}(to be|being)\\s+(around|here|alive)"
+      - "(should|just).{0,10}(disappear|stop existing|not be here|not wake up)"
+      - "didn'?t\\s+(have to|need to|wake|exist|have to deal)"
+      - "saying.{0,15}(scary|dark|concerning)\\s+(stuff|things).{0,20}(hurt|die|end|kill|alive|living)"
+      - "he.{0,5}(don'?t|doesn'?t|didn'?t).{0,5}(wanna|want to).{0,5}be\\s+here"
+      # --- passive ideation ---
+      - "(wish|hope|pray)\\s+(I\\s+)?(wouldn'?t|didn'?t|don'?t)\\s+(wake|exist|have to)"
+      # --- method contemplation ---
+      - "(stared at|looking at|holding)\\s+(the\\s+)?(pill|bridge|gun|rope|knife|razor|edge)"
+      # --- heaviness/emptiness cluster (MINIMIZER/indirect disclosure) ---
+      - "(heavy|empty|tired|fuzzy|dark).{0,30}(feeling|felt|feels|everything)"
+      # --- medication staring/fixation ---
+      - "(stared?\\s+at|looking\\s+at|keep\\s+looking).{0,10}(medication|pill|bottle|drug)"
+      # --- progressive disclosure phrases ---
+      - "everyone\\s+would\\s+be\\s+better\\s+off\\s+without"
+      - "things\\s+have\\s+been\\s+harder"
+      - "can'?t\\s+see\\s+a\\s+way\\s+forward"
+      # --- proxy disclosure ---
+      - "(asking|this is)\\s+(for|about)\\s+a\\s+friend"
+      # --- farewell behavior ---
+      - "(giving away|gave away|giving out)\\s+(my\\s+)?(things|stuff|belongings|possessions)"
+      - "(wrote|writing|written)\\s+(a\\s+)?(letter|note|goodbye|farewell)"
+      - "(tying|tied|putting)\\s+(up\\s+)?(loose ends|affairs|things in order)"
+  low:
+    partials:
+      - "hopeless"
+      - "suicidal"
+      - "self-harm"
+      - "ending it"
+      - "don't want to be here"
+      - "kill myself"
+      - "not worth living"
+      - "stopped existing"
+      - "wanna disappear"
+      - "not be here"
+      - "passing thought about"
+      - "everyone gets those thoughts"
+      - "not going to do anything but"
+      - "burden"
+      - "what's the point"
+      - "done with everything"
+
+negation_handling:
+  patterns:
+    - "not suicidal"
+    - "no thoughts of self-harm"
+    - "don't want to hurt myself"
+    # --- administrative / routine context suppression ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "when can I come in"
+    - "medication refill"
+    - "need a refill"
+    - "routine check"
+    - "just a question"
+    - "appointment timing"
+  action: downgrade_confidence
diff --git a/list/taxonomy/syncope/flows/clarify.yaml b/list/taxonomy/syncope/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..52ab558f35c19471e2e1793db1e1419278890249
--- /dev/null
+++ b/list/taxonomy/syncope/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: syncope
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: syncope_clarify
+      goal: "Ask patient to describe their syncope symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - syncope_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/syncope/flows/escalate_r3.yaml b/list/taxonomy/syncope/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..64d0e28cd868fa94ea576c466c4e30928d765e87
--- /dev/null
+++ b/list/taxonomy/syncope/flows/escalate_r3.yaml
@@ -0,0 +1,38 @@
+flow_id: escalate_r3
+type: escalation
+domain: syncope
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Inform patient this requires immediate clinical attention and they will
+      be transferred
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/syncope/flows/handoff.yaml b/list/taxonomy/syncope/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3394b174a60fea7543c688a4eb88b79f3eebf0d9
--- /dev/null
+++ b/list/taxonomy/syncope/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: syncope
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: syncope_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: syncope_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/syncope/rules.yaml b/list/taxonomy/syncope/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..500514913226f76dedc94f5246d16d1bc7c3f29c
--- /dev/null
+++ b/list/taxonomy/syncope/rules.yaml
@@ -0,0 +1,21 @@
+domain: syncope
+target_risk_class: R3
+
+decision_rules:
+  - id: syncope_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r3
+
+  - id: syncope_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r3
+
+  - id: syncope_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/syncope/triggers.yaml b/list/taxonomy/syncope/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7a2701370b9da8a394dab7ee14f7215799db03d3
--- /dev/null
+++ b/list/taxonomy/syncope/triggers.yaml
@@ -0,0 +1,157 @@
+domain: syncope
+priority: 95
+
+lexical_signals:
+  high:
+    phrases:
+      - "passed out"
+      - "lost consciousness"
+      - "fainted"
+      - "blacked out"
+      - "collapsed"
+      - "syncope"
+      - "fell unconscious"
+      - "fainting spell"
+      - "I fainted"
+      - "just fainted"
+    regex:
+      - "(passed|blacked|black)\\s+out"
+      - "lost\\s+consciousness"
+      - "(faint|collaps)(ed|ing)"
+      - "eyes\\s+(kinda\\s+|kind\\s+of\\s+|just\\s+)?(rolled|went\\s+back)"
+      - "(slumped|crumpled|went\\s+limp)"
+      - "I\\s+did\\s+(black|pass)\\s+out"
+      - "(woke|came\\s+to).{0,10}(on\\s+the\\s+)?(floor|ground)"
+      # --- witness report patterns ---
+      - "(found|saw)\\s+(him|her|them|my).{0,15}(on\\s+)?(the\\s+)?(floor|ground|lying|collapsed)"
+      - "(he|she|they|my).{0,15}(collapsed|went\\s+down|fell\\s+over|crumpled)"
+      - "(husband|wife|father|mother|son|daughter|dad|mom).{0,15}(passed\\s+out|fainted|collapsed|went\\s+down)"
+      # --- post-event confusion ---
+      - "(doesn'?t|didn'?t|don'?t)\\s+remember\\s+(falling|going\\s+down|what\\s+happened|how)"
+      - "(confused|disoriented|dazed)\\s+(after|when|once).{0,15}(woke|came\\s+to)"
+      - "(came\\s+to|woke\\s+up).{0,15}(confused|didn'?t\\s+know|disoriented)"
+      # --- associated symptoms before syncope ---
+      - "(heart|pulse)\\s+(racing|pounding|fast).{0,20}(then|before).{0,15}(passed|blacked|fainted|collapsed)"
+      - "(dizzy|lightheaded|woozy).{0,15}(then|and\\s+then|before).{0,15}(fell|fainted|passed|collapsed|went\\s+down)"
+      - "(sweaty|sweating|clammy).{0,15}(then|and).{0,15}(passed|blacked|fainted|collapsed)"
+  medium:
+    phrases:
+      - "almost fainted"
+      - "felt like I was going to pass out"
+      - "nearly blacked out"
+      - "presyncope"
+      - "lost my balance and fell"
+      - "went down suddenly"
+      - "quick fainting spell"
+      - "blanked out"
+      - "sort of blanked out"
+      - "was on the floor"
+      - "woke up on the floor"
+      - "scared I'm gonna pass out"
+      - "feeling like I might faint"
+      - "don't remember going down"
+      - "don't remember falling"
+      - "next thing I knew I was on the floor"
+      - "I guess I did black out"
+      - "I guess I did pass out"
+      - "eyes rolled and I slumped"
+      - "said my eyes rolled"
+      - "said I slumped"
+      - "looked kind of gray and sweaty"
+      # --- additional naturalistic ---
+      - "they said I went out"
+      - "lights just went out"
+      - "everything went black"
+      # --- witness report patterns ---
+      - "found him on the floor"
+      - "found her on the floor"
+      - "she collapsed"
+      - "he collapsed"
+      - "went down without warning"
+      - "just dropped"
+      - "saw them fall"
+      - "watched her go down"
+      - "watched him go down"
+      # --- near-syncope patterns ---
+      - "thought I was going to faint"
+      - "almost went down"
+      - "nearly fell over"
+      - "felt myself going"
+      - "started to black out"
+      - "was about to pass out"
+      - "felt like passing out"
+      - "almost lost it"
+      - "grayed out"
+      - "vision started going dark"
+      # --- post-event confusion ---
+      - "didn't know where I was"
+      - "confused when I came to"
+      - "didn't recognize anyone"
+      - "took a while to remember"
+      - "groggy after"
+      - "memory is fuzzy"
+      # --- associated symptoms ---
+      - "heart was racing then I passed out"
+      - "got really dizzy then fell"
+      - "sweating then blacked out"
+      - "nauseous before I fainted"
+      - "vision tunneled then I went down"
+    regex:
+      - "(almost|nearly|about to|gonna|going to)\\s+(faint|pass out|black out|collapse)"
+      - "(woke|came to|found myself).{0,10}(on the floor|on the ground)"
+      - "then\\s+I\\s+was\\s+on\\s+the\\s+(floor|ground)"
+      - "(blanked|zoned)\\s+out"
+      - "feeling.{0,10}(faint|woozy|dizzy).{0,20}(fall|drop|pass out)"
+      - "next\\s+thing\\s+I\\s+knew.{0,15}(floor|ground|sitting|lying)"
+      - "(slumped|crumpled).{0,10}(over|down|forward|in)"
+  low:
+    partials:
+      - "vasovagal"
+      - "near-syncope"
+      - "syncope"
+
+negation_handling:
+  patterns:
+    - "didn't faint"
+    - "didn't pass out"
+    - "no loss of consciousness"
+    - "stayed conscious"
+    - "never lost consciousness"
+    - "didn't lose consciousness"
+    - "no syncope"
+    - "haven't fainted"
+    - "haven't passed out"
+    - "have not fainted"
+    - "have not passed out"
+    - "no fainting"
+    - "not fainted"
+    - "not passed out"
+    - "never fainted"
+    - "never passed out"
+    - "haven't blacked out"
+    - "didn't black out"
+    - "haven't collapsed"
+    - "didn't collapse"
+    - "no blackout"
+    - "no passing out"
+    # --- historical / administrative context (FDA-safe) ---
+    - "years ago"
+    - "in the past"
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+    - "appointment timing"
+  # Changed to 'suppress' for R1 false escalation reduction.
+  # Administrative context should suppress the domain.
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_has_condition: ["I48.*"]
+      reason: "Afib with syncope suggests hemodynamic instability"
+    - when:
+        patient_on_medication_class: ["antihypertensives", "beta_blockers"]
+      reason: "Medication-induced syncope risk"
diff --git a/list/taxonomy/thunderclap_headache/flows/clarify.yaml b/list/taxonomy/thunderclap_headache/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..77a386a9c07a5bbd6c38cd3c5f4b23dcb06c3ed5
--- /dev/null
+++ b/list/taxonomy/thunderclap_headache/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: thunderclap_headache
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: thunderclap_headache_clarify
+      goal: "Ask patient to describe their thunderclap headache symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - thunderclap_headache_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/thunderclap_headache/flows/escalate_r3.yaml b/list/taxonomy/thunderclap_headache/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7dee7f6b2cfd896939f8985be211e3d7d34044da
--- /dev/null
+++ b/list/taxonomy/thunderclap_headache/flows/escalate_r3.yaml
@@ -0,0 +1,38 @@
+flow_id: escalate_r3
+type: escalation
+domain: thunderclap_headache
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Inform patient this requires immediate clinical attention and they will
+      be transferred
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/thunderclap_headache/flows/handoff.yaml b/list/taxonomy/thunderclap_headache/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..56d7a5dda78a92754ad5bae87b19a3216a2eb292
--- /dev/null
+++ b/list/taxonomy/thunderclap_headache/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: thunderclap_headache
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: thunderclap_headache_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: thunderclap_headache_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/thunderclap_headache/rules.yaml b/list/taxonomy/thunderclap_headache/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d3f217c73d2e1d367af7259731c598ba841b3596
--- /dev/null
+++ b/list/taxonomy/thunderclap_headache/rules.yaml
@@ -0,0 +1,21 @@
+domain: thunderclap_headache
+target_risk_class: R3
+
+decision_rules:
+  - id: thunderclap_headache_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r3
+
+  - id: thunderclap_headache_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r3
+
+  - id: thunderclap_headache_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/thunderclap_headache/triggers.yaml b/list/taxonomy/thunderclap_headache/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c2cc658706dee9893e9a56c36185786ba2583e75
--- /dev/null
+++ b/list/taxonomy/thunderclap_headache/triggers.yaml
@@ -0,0 +1,185 @@
+domain: thunderclap_headache
+priority: 89
+
+lexical_signals:
+  high:
+    phrases:
+      - "worst headache of my life"
+      - "sudden severe headache"
+      - "thunderclap headache"
+      - "head feels like it's exploding"
+      - "excruciating headache came on suddenly"
+      - "worst headache ever"
+      - "worst headache I've ever had"
+      - "explosive headache"
+      - "headache hit like a bolt"
+      - "sudden intense headache"
+    regex:
+      - "worst\\s+(headache|head\\s*ache|head\\s+pain)"
+      - "(sudden|instant|immediate|abrupt).{0,25}(headache|head\\s*ache|head\\s+pain)"
+      - "(headache|head\\s*ache|head\\s+pain).{0,25}(worst|terrible|excruciating|explosive|thunderclap|intense|severe)"
+      - "(headache|head\\s*ache).{0,20}(like a (bolt|switch|bomb|explosion))"
+      - "(headache|head\\s*ache|head).{0,20}(hit|struck|came on|started).{0,15}(sudden|instant|immediate|out of nowhere|fast)"
+      - "thunderclap"
+      - "\\bhead\\b.{0,10}(feels like|like).{0,10}(explod|split|burst|crack|gonna blow)"
+      - "\\bhead\\b.{0,10}(splitting|pounding|exploding|throbbing).{0,15}(never|worst|ever|so bad|terrible)"
+  medium:
+    phrases:
+      - "severe headache out of nowhere"
+      - "worst headache I've had"
+      - "headache hit suddenly and severely"
+      - "severe headache came on suddenly"
+      - "headache that peaked immediately"
+      - "headache like a switch flipped"
+      - "headache during exertion"
+      - "headache and stiff neck"
+      - "headache and vomiting"
+      - "headache with neck stiffness"
+      - "went from fine to worst headache"
+      - "headache hit out of nowhere"
+      - "headache and neck feels stiff"
+      - "really sudden headache"
+      # --- additional patterns ---
+      - "peaked immediately"
+      - "hit like lightning"
+      - "10 out of 10 within seconds"
+      - "never felt anything like this"
+      - "different from my migraines"
+      - "threw up from the pain"
+      - "neck is so stiff"
+      - "head felt like it popped"
+      - "worst pain of my life in my head"
+      # --- Phase 4: expanded patterns for missed scenarios ---
+      - "worst headache of my life"
+      - "head is exploding"
+      - "like a bomb went off"
+      - "screaming from the pain"
+      # --- sudden onset superlatives ---
+      - "worst pain I've ever felt"
+      - "worst pain of my life"
+      - "like nothing I've ever felt"
+      - "like nothing before"
+      - "never experienced anything like this"
+      - "I've never experienced anything like this"
+      - "I've never felt anything like this"
+      - "unlike anything I've felt"
+      - "completely different from"
+      - "this is different"
+      - "it's different from"
+      - "different from my usual"
+      # --- sudden onset descriptors ---
+      - "hit me like a truck"
+      - "hit like a truck"
+      - "like someone hit me"
+      - "like a baseball bat"
+      - "hit me with a hammer"
+      - "like a hammer"
+      - "like a switch flipped"
+      - "someone flipped a switch"
+      - "flipped a switch"
+      - "out of nowhere"
+      - "came out of nowhere"
+      - "came on so fast"
+      - "came on suddenly"
+      - "came on instantly"
+      - "pain was instantaneous"
+      - "pain was instant"
+      - "instant 10/10"
+      - "instant ten out of ten"
+      - "ten out of ten"
+      - "10/10"
+      - "just BAM"
+      - "then BAM"
+      - "and then boom"
+      - "suddenly boom"
+      # --- exertional onset ---
+      - "headache during sex"
+      - "headache while lifting"
+      - "while bending over"
+      - "while straining"
+      - "during deadlifts"
+      # --- associated symptoms with headache ---
+      - "stiff neck with headache"
+      - "neck stiff with this headache"
+      - "vomiting with this headache"
+      - "threw up with the headache"
+      # --- minimizer reversals ---
+      - "probably nothing but worst"
+      - "probably overreacting but worst"
+      - "don't want to overreact but worst"
+      - "don't want to be dramatic but"
+      - "scary different"
+    regex:
+      - "(headache|head\\s+pain).{0,30}(neck.{0,10}(stiff|tight|rigid)|stiff\\s+neck)"
+      - "(neck.{0,10}(stiff|tight|rigid)).{0,30}(headache|head\\s+pain)"
+      - "(headache|head\\s+pain|\\bhead\\b).{0,30}(vomit|threw up|nausea)"
+      - "(headache|head\\s+pain).{0,25}(exert|lift|strain|exercise|deadlift|workout)"
+      - "peak.{0,10}(immediate|instant|right away)"
+      - "(headache|head\\s+pain|head is).{0,25}(killing|splitting|pounding|crushing|unbearable)"
+      - "(never|worst|most).{0,15}(headache|head\\s+pain).{0,10}(ever|in my life|I've)"
+      # --- exertional onset ---
+      - "headache\\s+(during|while|when)\\s+(sex|lifting|straining|exertion|exercise|bending)"
+      # --- vomiting + headache ---
+      - "(projectile|started)\\s+vomiting\\s+(with|and)\\s+(this\\s+)?headache"
+      # --- never felt this ---
+      - "never\\s+(felt|had|experienced).{0,15}(anything|headache|pain).{0,10}(like this|this bad|this severe)"
+      # --- Phase 4: expanded patterns for missed scenarios ---
+      - "(he|she).{0,30}(scream|yell|cry).{0,20}(head|pain)"
+      - "(keep|keeps).{0,20}(say|saying).{0,30}(never|nothing|worst).{0,20}(felt|like)"
+      - "(hit|struck|smash).{0,15}(hammer|wall|freight|truck|bomb|bat)"
+      - "(can't|cannot).{0,20}(think|thought).{0,10}(straight|together|clearly)"
+      - "threw up.{0,30}(minute|min|second|after).{0,15}headache"
+      - "headache.{0,30}threw up"
+      # --- superlative after minimization ---
+      - "(just|probably|could be).{0,30}(worst|never\\s+felt|most\\s+severe)"
+      # --- minimization then sudden onset ---
+      - "(headache|just\\s+headache).{0,30}(usual|sometimes|nothing).{0,30}(sudden|quick|fast)"
+      # --- sudden onset superlative patterns ---
+      - "(worst|most\\s+severe|terrible).{0,15}(pain|headache).{0,15}(ever|of my life|I'?ve)"
+      - "like\\s+nothing.{0,15}(I'?ve|before|ever)"
+      - "unlike\\s+(anything|any).{0,15}(I'?ve|before|ever)"
+      - "(completely|totally|entirely)\\s+different\\s+from"
+      # --- sudden onset impact descriptors ---
+      - "(hit|struck).{0,10}(me|him|her).{0,10}(like\\s+a|with\\s+a).{0,10}(truck|hammer|bat|bolt)"
+      - "like\\s+(someone|a).{0,10}(hit|struck).{0,10}(me|my head)"
+      - "(like\\s+)?a\\s+(switch|bolt|bomb|hammer|truck|baseball bat)"
+      - "(flipped|flip).{0,10}(a\\s+)?switch"
+      - "(out of|outta)\\s+nowhere"
+      - "came\\s+(on|out).{0,10}(so\\s+)?(fast|suddenly|instantly|quick)"
+      # --- instant severity ---
+      - "(pain|headache).{0,10}(was|is).{0,10}(instantaneous|instant|immediate)"
+      - "instant.{0,10}(10|ten).{0,5}(/|out of).{0,5}(10|ten)"
+      - "(10|ten).{0,5}(/|out of).{0,5}(10|ten)"
+      - "(BAM|boom|bam|BOOM)"
+      # --- exertional onset patterns ---
+      - "headache.{0,15}(during|while|when).{0,10}(sex|lifting|straining|bending|deadlift)"
+      - "(while|when|during).{0,10}(bending|lifting|straining|exert).{0,20}headache"
+      # --- associated symptoms patterns ---
+      - "(stiff|tight)\\s+neck.{0,20}(headache|head\\s+pain|this)"
+      - "(my\\s+)?neck.{0,10}(feels|is).{0,10}(stiff|tight|rigid).{0,20}headache"
+      - "(threw up|vomit|nausea).{0,20}(headache|head\\s+pain|this)"
+      # --- minimizer reversal patterns ---
+      - "(probably|don'?t want to).{0,20}(overreact|dramatic|nothing).{0,20}(but|worst|terrible|severe)"
+      - "(scary|scaring).{0,10}different"
+      - "(know|sure).{0,10}(sounds|seems).{0,10}(serious|bad)"
+  low:
+    partials:
+      - "thunderclap"
+      - "subarachnoid"
+      - "worst headache"
+      - "sudden headache"
+      - "severe headache"
+
+negation_handling:
+  patterns:
+    - "headache is gone"
+    - "no headache"
+    - "headache resolved"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
diff --git a/list/taxonomy/tobacco_use_active/flows/cessation_resources.yaml b/list/taxonomy/tobacco_use_active/flows/cessation_resources.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..afd114ea8bae23d40211b7711030466bdf8abf08
--- /dev/null
+++ b/list/taxonomy/tobacco_use_active/flows/cessation_resources.yaml
@@ -0,0 +1,23 @@
+flow_id: cessation_resources
+type: resolution
+domain: tobacco_use_active
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: tobacco_cessation_resources
+      goal: "Offer cessation resources in a supportive, non-judgmental way. Inform care team will follow up."
+      tone: warm_supportive
+      must_include:
+        - "care team"
+        - "resources"
+      must_not:
+        - "bad habit"
+        - "you need to quit"
+        - "you should stop"
+        - "lecture"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/tobacco_use_active/flows/clarify.yaml b/list/taxonomy/tobacco_use_active/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..f2d07bdc646ff3a6345c59324693656427a069cb
--- /dev/null
+++ b/list/taxonomy/tobacco_use_active/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: tobacco_use_active
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: tobacco_clarify
+      goal: "Ask the patient to tell more about their tobacco or nicotine use"
+      tone: warm_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "bad habit"
+        - "you should quit"
+      max_questions: 1
+    collects:
+      - tobacco_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/tobacco_use_active/flows/tobacco_assessment.yaml b/list/taxonomy/tobacco_use_active/flows/tobacco_assessment.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7dbcf12732e5da85eb28ccca09fc7ecc3e414cc9
--- /dev/null
+++ b/list/taxonomy/tobacco_use_active/flows/tobacco_assessment.yaml
@@ -0,0 +1,54 @@
+flow_id: tobacco_assessment
+type: assessment
+domain: tobacco_use_active
+
+required_slots:
+  - tobacco_type
+  - tobacco_frequency
+  - quit_interest
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: tobacco_assess_step1
+      goal: "Assess the type and frequency of tobacco or nicotine use"
+      tone: warm_professional
+      must_include:
+        - "tobacco"
+      must_ask:
+        - "What type of tobacco or nicotine product do you use?"
+        - "About how often do you use it?"
+      must_not:
+        - "bad habit"
+        - "shouldn't"
+        - "lecture"
+      max_questions: 2
+    collects:
+      - tobacco_type
+      - tobacco_frequency
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: tobacco_assess_step2
+      goal: "Assess whether the patient has interest in quitting or reducing use"
+      tone: warm_professional
+      must_include:
+        - "quit"
+      must_ask:
+        - "Have you thought about cutting back or quitting?"
+      must_not:
+        - "you should quit"
+        - "bad for you"
+        - "lecture"
+        - "judgmental"
+      max_questions: 1
+    collects:
+      - quit_interest
+
+exit:
+  on_complete: evaluate_concern
+  on_concern: cessation_resources
+  on_low_risk: cessation_resources
+  on_unclear: cessation_resources
diff --git a/list/taxonomy/tobacco_use_active/rules.yaml b/list/taxonomy/tobacco_use_active/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..6da386f27708d49bac2a378ce033f2d11fb57c1b
--- /dev/null
+++ b/list/taxonomy/tobacco_use_active/rules.yaml
@@ -0,0 +1,21 @@
+domain: tobacco_use_active
+target_risk_class: R0
+
+decision_rules:
+  - id: tobacco_use_active_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: tobacco_assessment
+
+  - id: tobacco_use_active_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: tobacco_assessment
+
+  - id: tobacco_use_active_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/tobacco_use_active/triggers.yaml b/list/taxonomy/tobacco_use_active/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..72e1dee945691099b623be974807fb7622bb91a4
--- /dev/null
+++ b/list/taxonomy/tobacco_use_active/triggers.yaml
@@ -0,0 +1,75 @@
+domain: tobacco_use_active
+priority: 25
+
+lexical_signals:
+  high:
+    phrases:
+      - "still smoking a pack a day"
+      - "smoking more than ever"
+      - "can't quit smoking"
+      - "vaping all day long"
+      - "chewing tobacco every day"
+      - "smoke two packs a day"
+      - "been smoking for years and can't stop"
+      - "addicted to cigarettes"
+      - "addicted to nicotine"
+      - "chain smoking"
+      - "go through a pack a day"
+      - "smoking since I was a teenager"
+      - "tried to quit smoking but can't"
+      - "heavy smoker"
+      - "vaping constantly"
+    regex:
+      - "(still|keep|can't\\s+stop|can't\\s+quit).{0,10}(smoking|vaping|using\\s+tobacco|chewing)"
+      - "(pack|packs)\\s+(a|per|every)\\s+day"
+      - "(addicted|dependent|hooked).{0,10}(cigarette|nicotine|tobacco|vaping)"
+      - "(heavy|chain).{0,5}(smok|vap)"
+  medium:
+    phrases:
+      - "still smoking"
+      - "I smoke"
+      - "vaping"
+      - "cigarettes"
+      - "nicotine"
+      - "chewing tobacco"
+      - "e-cigarette"
+      - "pack a day"
+      - "smoke a few cigarettes"
+      - "use nicotine"
+      - "smoking on and off"
+      - "social smoker"
+      - "have a cigarette"
+      - "smoke occasionally"
+      - "dip tobacco"
+    regex:
+      - "(still|currently|do|am)\\s+(smok|vap|using\\s+tobacco|chewing)"
+      - "(cigarette|nicotine|tobacco|e-cigarette|vape).{0,10}(use|user|every|daily)"
+  low:
+    partials:
+      - "smoke"
+      - "cigarette"
+      - "nicotine"
+      - "vape"
+      - "tobacco"
+
+negation_handling:
+  patterns:
+    - "i quit smoking"
+    - "stopped smoking"
+    - "don't smoke"
+    - "gave up cigarettes"
+    - "no longer smoking"
+    - "kicked the habit"
+    - "smoke free"
+    - "not a smoker"
+    - "i quit vaping"
+    - "don't vape"
+    - "never smoked"
+    - "don't use tobacco"
+    - "quit years ago"
+    - "haven't smoked in"
+    - "stopped using nicotine"
+    - "tobacco free"
+    - "gave up tobacco"
+    - "clean for years"
+  action: downgrade_confidence
diff --git a/list/taxonomy/uncontrolled_pain/flows/clarify.yaml b/list/taxonomy/uncontrolled_pain/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..cf3de1a50dee85d69f01b3cea3f23373a1106306
--- /dev/null
+++ b/list/taxonomy/uncontrolled_pain/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: uncontrolled_pain
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: uncontrolled_pain_clarify
+      goal: "Ask patient to describe their uncontrolled pain symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - uncontrolled_pain_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/uncontrolled_pain/flows/escalate_r2.yaml b/list/taxonomy/uncontrolled_pain/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ae02750447b75a65f95b4e6292fd797eac9e4b11
--- /dev/null
+++ b/list/taxonomy/uncontrolled_pain/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: uncontrolled_pain
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/uncontrolled_pain/flows/handoff.yaml b/list/taxonomy/uncontrolled_pain/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..808fa09a2fdcd06b7f716433c18a19c3be380366
--- /dev/null
+++ b/list/taxonomy/uncontrolled_pain/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: uncontrolled_pain
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: uncontrolled_pain_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: uncontrolled_pain_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/uncontrolled_pain/flows/safety_screen.yaml b/list/taxonomy/uncontrolled_pain/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..070fd2d6e44c35928191d18b5381e01ddedde4ab
--- /dev/null
+++ b/list/taxonomy/uncontrolled_pain/flows/safety_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: safety_screen
+type: screening
+domain: uncontrolled_pain
+
+required_slots:
+  - pain_severity
+  - pain_location
+  - medications_tried
+  - pain_duration
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "pain severity"
+        - "pain location"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - pain_severity
+      - pain_location
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "medications tried"
+        - "pain duration"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - medications_tried
+      - pain_duration
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/list/taxonomy/uncontrolled_pain/rules.yaml b/list/taxonomy/uncontrolled_pain/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..269dc4ce56bbd9c65fa5126392458df16a15e916
--- /dev/null
+++ b/list/taxonomy/uncontrolled_pain/rules.yaml
@@ -0,0 +1,27 @@
+domain: uncontrolled_pain
+target_risk_class: R2
+
+decision_rules:
+  - id: uncontrolled_pain_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: uncontrolled_pain_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: uncontrolled_pain_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: uncontrolled_pain_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/uncontrolled_pain/triggers.yaml b/list/taxonomy/uncontrolled_pain/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..dd66c6307f10c8fde4ffb72f8450bc3c377bd38c
--- /dev/null
+++ b/list/taxonomy/uncontrolled_pain/triggers.yaml
@@ -0,0 +1,227 @@
+domain: uncontrolled_pain
+priority: 70
+
+lexical_signals:
+  high:
+    phrases:
+      - "pain is out of control"
+      - "pain is 10 out of 10"
+      - "unbearable pain despite medication"
+      - "worst pain of my life"
+      - "it barely touched it"
+      - "in a lot of pain and I can't get it under control"
+      - "pain medication is not doing anything"
+      - "I took my pills and it did nothing"
+      - "screaming in pain"
+      - "crying from the pain"
+      - "the pain is so bad I can't move"
+      - "I can't take this pain anymore"
+      - "nothing is touching this pain"
+      - "been in agony all day"
+      - "pain is absolutely unbearable"
+      - "doubled over in pain"
+      - "I want to go to the ER for the pain"
+      - "pain has me in tears"
+    regex:
+      - "pain.*out\\s+of\\s+control"
+      - "pain.*10\\s*(out\\s+of|/)\\s*10"
+      - "pain.*(won[']?t|doesn[']?t|didn[']?t)\\s+(stop|quit|go away|let up|settle)"
+      - "(took|tried|take|taken).*(ibuprofen|tylenol|advil|acetaminophen|medication|pills?|meds?|oxycodone|percocet|norco|vicodin|tramadol|hydrocodone).*(didn[']?t|not|barely|won[']?t|doesn[']?t)\\s*(help|work|touch|do)"
+      - "(can[']?t|unable\\s+to)\\s+(get\\s+)?comfort"
+      - "medication\\s+isn[']?t\\s+touch"
+      - "pain\\s+(that\\s+)?won[']?t\\s+quit"
+      - "pain\\s+won[']?t\\s+stop"
+      - "(scream|cry|sob|moan|groan|wail|holler|yell).{0,10}(from|in|with|because).{0,10}(the\\s+)?pain"
+      - "pain.{0,15}(scream|cry|sob|moan|groan|wail|holler|yell)"
+      - "(can[']?t|unable).{0,5}(to\\s+)?(take|stand|handle|bear|tolerate|endure).{0,10}(this\\s+|the\\s+)?pain"
+      - "nothing.{0,10}(is\\s+)?(touch|help|work).{0,5}(ing|s)?.{0,10}(this\\s+|the\\s+)?pain"
+      - "pain.{0,10}(so\\s+bad|terrible|horrible|excruciating|agonizing)"
+      - "(doubled|curled|bent).{0,5}(over|up).{0,10}(in\\s+|from\\s+|with\\s+)?pain"
+      - "want.{0,10}(go\\s+to|visit).{0,10}(the\\s+)?(ER|emergency|hospital).{0,10}(for\\s+)?(the\\s+)?pain"
+      - "pain.{0,10}(has|got|have).{0,5}me.{0,5}(in\\s+)?tears"
+  medium:
+    phrases:
+      - "still in a lot of pain"
+      - "pain is getting worse"
+      - "pain keeps increasing"
+      - "intense pain"
+      - "8 out of 10"
+      - "9 out of 10"
+      - "guarding and moving slow"
+      - "in a lot of pain"
+      - "everything hurts"
+      - "this awful hurting"
+      - "pain woke me up in the middle of the night"
+      - "can't get comfortable no matter what I do"
+      - "I have tried everything for this pain"
+      - "took extra pills and it still hurts"
+      - "the pain keeps coming back stronger"
+      - "hurting way more than yesterday"
+      - "pain is spreading"
+      - "my whole body aches"
+      - "I can't even sit still the pain is so bad"
+      - "I have not slept in two days from the pain"
+      - "the medicine only takes the edge off"
+      - "it helps for maybe an hour then comes right back"
+      - "the pain is making me sick to my stomach"
+      - "rated my pain a nine"
+      - "throbbing non stop"
+      # --- MINIMIZER coverage ---
+      - "pain isn't that bad really"
+      - "I can handle it, it's just annoying"
+      - "probably just need to rest"
+      - "it's there but I'm managing"
+      - "just a bit of pain"
+      - "discomfort more than pain"
+      - "it's bearable"
+      - "not terrible but it won't go away"
+      - "pain comes and goes, probably nothing"
+      # --- additional patterns ---
+      - "pain is making me throw up"
+      - "can't function because of the pain"
+      - "I haven't eaten because of the pain"
+      - "pain keeps me up all night"
+      # --- Phase 6: R2 recall expansion ---
+      - "pain is unbearable"
+      - "can't take it anymore"
+      - "nothing touches the pain"
+      - "worst pain ever"
+      - "pain making me cry"
+    regex:
+      - "pain\\s+isn[']?t\\s+(getting\\s+)?better"
+      - "pain\\s+medication\\s+not\\s+working"
+      - "can[']?t\\s+manage\\s+the\\s+pain"
+      - "(hurting|pain).{0,30}(a\\s+lot|really|so)\\s*(bad|much|intense)?"
+      - "pain.*([89]|eight|nine)\\s*(out\\s+of|/)\\s*10"
+      - "pain.*(spike|spikes|spiking|waves?)"
+      - "(pain|hurt|ache|sore|throb).{0,40}(can[']?t|unable)\\s+(sleep|focus|sit|eat|work|calm|function|concentrate|think)"
+      - "(can[']?t|unable)\\s+(sleep|focus|sit|eat|work|calm|function|concentrate|think).{0,40}(pain|hurt|ache|sore|throb|because of|from the|due to)"
+      - "keep\\s+(pacing|shifting|moving)"
+      - "it[']?s\\s+messing\\s+with"
+      - "making\\s+me\\s+snappy"
+      - "can[']?t\\s+focus\\s+on\\s+anything"
+      - "can[']?t\\s+sleep"
+      - "(just|really)\\s+(hurting|uncomfortable)"
+      - "hurting\\s+(a\\s+lot|bad|so)"
+      - "hard\\s+to\\s+manage"
+      - "pain\\s+thing"
+      - "this\\s+pain"
+      - "just\\s+this\\s+pain"
+      - "(snappy|irritable|cranky).*pain"
+      - "pain.*(snappy|irritable|cranky)"
+      - "it\\s+spikes"
+      - "can[']?t\\s+get\\s+comfy"
+      - "hurts\\s+(so|really|a\\s+lot|bad|worse|terribly|horribly)"
+      - "keeps?\\s+interrupting"
+      - "annoying\\s+pain"
+      - "(lack|loss)\\s+of\\s+sleep"
+      - "irritable.*sleep"
+      - "sleep.*irritable"
+      - "(area|whole|entire|every)\\s+hurts"
+      - "pain.{0,10}(woke|wake).{0,5}(me\\s+)?up"
+      - "(woke|wake).{0,10}up.{0,10}(from|with|because).{0,10}pain"
+      - "tried\\s+everything.{0,10}(for\\s+)?(the\\s+)?pain"
+      - "(took|take|taking)\\s+(extra|more|double|two|another).{0,10}(pill|med|dose|tablet)"
+      - "pain.{0,10}(com|keep|came|keeps).{0,10}(back|return)"
+      - "(worse|more|bad).{0,5}(than|er).{0,10}yesterday"
+      - "pain.{0,10}(spread|radiat|mov)"
+      - "(whole|entire)\\s+(body|side).{0,10}(ache|hurt|pain)"
+      - "(medicine|med|pill|medication).{0,10}(only|just|barely).{0,10}(take|help)"
+      - "(help|work|last).{0,10}(for\\s+)?(maybe\\s+)?(an\\s+hour|a\\s+bit|a\\s+little).{0,10}(then|and|but)"
+      - "pain.{0,10}(mak|made).{0,10}(me\\s+)?(sick|nauseous|throw|vomit)"
+      - "(throb|puls|pound).{0,5}(ing|s).{0,10}(non\\s*stop|constant|all\\s+day|all\\s+night)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(just|only).{0,10}(a\\s+)?(little|bit|slight|annoying|nagging).{0,10}(pain|ache|hurt|discomfort|sore)"
+      - "(pain|hurt|ache|sore).{0,15}(not that bad|bearable|manageable|tolerable|I can handle).{0,15}(but|though|just|won't)"
+      - "(pain|hurt|ache).{0,15}(won't|doesn't|not|never).{0,10}(go away|stop|let up|ease|quit|improve|subside)"
+      - "(probably|might be).{0,10}(just|nothing|need to rest|normal|muscle).{0,15}(pain|hurt|ache|sore)"
+      - "(discomfort|uncomfortable).{0,10}(more than|rather than|not really|wouldn't call it).{0,10}(pain|sharp|severe)"
+      # --- Low-literacy minimization patterns (R2 recall) ---
+      - "(not terrible|not that bad|nothing crazy).{0,15}(or anything|really|but)"
+      - "(back|hip|knee|shoulder|neck)\\s+thing.{0,15}(going on|bothering|acting up)"
+      - "(just|kind of|sort of)\\s+(bugging|bothering|nagging|annoying)\\s+me"
+      # --- Duration + minimization ---
+      - "(pain|hurt|ache).{0,30}(days?|weeks?|since).{0,20}(not bad|manage|handle|ice|heat|rest)"
+      - "(been|going on).{0,15}(days?|weeks?|while).{0,20}(not that bad|can handle|manage)"
+      # --- Functional impact patterns ---
+      - "(can't|unable to|hard to).{0,10}(do what I used to|do my usual|do things)"
+      - "(affecting|impacts?|interfering).{0,15}(my work|my job|daily|sleep|life)"
+      - "(hard|difficult|tough|struggling).{0,10}(to sleep|sleeping|to rest)"
+      - "(keeping|waking|wake).{0,10}(me up|up at night|me at night)"
+      # --- Phase 6: R2 recall expansion ---
+      - "pain.{0,20}(unbearable|intolerable|excruciating|can't take|can't stand)"
+      - "(nothing|meds|medication|pills).{0,20}(touch|help|work).{0,15}(the )?pain"
+      - "pain.{0,20}(making|makes).{0,10}(me )?(cry|scream|vomit|pass out)"
+      - "(worst|severe|extreme).{0,10}pain.{0,20}(ever|of my life|I've had)"
+  low:
+    partials:
+      - "uncontrolled pain"
+      - "pain worse"
+      - "pain not managed"
+      - "really hurting"
+      - "agony"
+      - "meds not working"
+      - "nothing helps"
+      - "excruciating"
+      - "hurting a lot"
+      - "pain spikes"
+      - "just hurting"
+      - "keep pacing"
+      - "uncomfortable"
+      - "throbbing"
+      - "can't sleep"
+      - "constant pain"
+      - "severe pain"
+      - "pills not working"
+      - "breakthrough pain"
+      - "writhing"
+
+negation_handling:
+  patterns:
+    - "pain is controlled"
+    - "medication is working"
+    - "pain is manageable"
+    - "pain is better"
+    - "pain went down"
+    - "pain is much better now"
+    - "the medication helped"
+    - "pain is under control"
+    - "feeling better after taking my meds"
+    - "pain went from a nine to a three"
+    - "manageable now"
+    - "the pain finally broke"
+    - "not in pain anymore"
+    - "pain free"
+    - "no pain at the moment"
+    - "comfortable right now"
+    - "pain has been fine"
+    - "meds are working great"
+    - "took my pills and it helped"
+    - "pain only when I move a certain way"
+    - "just a little sore"
+    - "mild discomfort"
+    - "it is just muscle soreness"
+    # --- worsening_chronic_pain (R1) routine context ---
+    - "chronic pain"
+    - "chronic back pain"
+    - "chronic lower back"
+    - "herniated disc"
+    - "flare-up"
+    - "flare up"
+    - "my usual pain"
+    - "my regular pain"
+    - "my baseline"
+    - "instead of my usual"
+    - "physical therapy"
+    - "PT referral"
+    - "pain management plan"
+    - "pain management appointment"
+    - "managing my pain"
+    - "been dealing with this for"
+    - "had this for years"
+    - "out of 10 instead of"
+    - "3 or 4 out of 10"
+    - "4 out of 10"
+    - "5 out of 10"
+    - "6 out of 10"
+  action: downgrade_confidence
diff --git a/list/taxonomy/urinary_retention/flows/clarify.yaml b/list/taxonomy/urinary_retention/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c64092910547d12d444e5dbb2e510d2ac160938f
--- /dev/null
+++ b/list/taxonomy/urinary_retention/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: urinary_retention
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: urinary_retention_clarify
+      goal: "Ask patient to describe their urinary retention symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - urinary_retention_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/urinary_retention/flows/escalate_r2.yaml b/list/taxonomy/urinary_retention/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..34a0263bf5bd2667ec8f59b7a369a9fdc8659839
--- /dev/null
+++ b/list/taxonomy/urinary_retention/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: urinary_retention
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/urinary_retention/flows/handoff.yaml b/list/taxonomy/urinary_retention/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e183da7d716417e45a79d10d720ca51ecd467368
--- /dev/null
+++ b/list/taxonomy/urinary_retention/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: urinary_retention
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: urinary_retention_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: urinary_retention_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/urinary_retention/flows/safety_screen.yaml b/list/taxonomy/urinary_retention/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5953f79ae9b89da169692bb2a33d25656c70d5e1
--- /dev/null
+++ b/list/taxonomy/urinary_retention/flows/safety_screen.yaml
@@ -0,0 +1,53 @@
+flow_id: safety_screen
+type: screening
+domain: urinary_retention
+
+required_slots:
+  - last_urination
+  - bladder_fullness
+  - pain_severity
+  - fluid_intake
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: safety_screen_step1
+      goal: "Gather initial details about the patient's symptoms"
+      tone: calm_urgent
+      must_include:
+        - "tell me"
+      must_ask:
+        - "last urination"
+        - "bladder fullness"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - last_urination
+      - bladder_fullness
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: safety_screen_step2
+      goal: "Gather additional details to complete the safety assessment"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "pain severity"
+        - "fluid intake"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - pain_severity
+      - fluid_intake
+
+exit:
+  on_complete: evaluate_risk
+  on_r2: escalate_r2
+  on_unclear: clarify
diff --git a/list/taxonomy/urinary_retention/rules.yaml b/list/taxonomy/urinary_retention/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8dc4411ac4515098677e7a7d40319e9739ee8c5e
--- /dev/null
+++ b/list/taxonomy/urinary_retention/rules.yaml
@@ -0,0 +1,27 @@
+domain: urinary_retention
+target_risk_class: R2
+
+decision_rules:
+  - id: urinary_retention_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: urinary_retention_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: urinary_retention_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: urinary_retention_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/urinary_retention/triggers.yaml b/list/taxonomy/urinary_retention/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0ffcd86e2dd1f16c97b053ac40de1760834a8a2d
--- /dev/null
+++ b/list/taxonomy/urinary_retention/triggers.yaml
@@ -0,0 +1,202 @@
+domain: urinary_retention
+priority: 66
+
+lexical_signals:
+  high:
+    phrases:
+      - "acute urinary retention"
+      - "unable to pass urine"
+      - "blocked bladder"
+      - "can't pee at all"
+      - "haven't urinated all day"
+      - "haven't been able to pee since yesterday"
+      - "nothing comes out when I try to pee"
+      - "I sit there and nothing happens"
+      - "bladder feels like it is going to burst"
+      - "can't urinate and my belly is swollen"
+      - "I have not peed in over twelve hours"
+      - "tried everything and I still can't go"
+      - "bladder is full but nothing comes out"
+      - "it won't come out no matter how hard I push"
+      - "completely unable to void"
+      - "I need a catheter I can't pee"
+      - "belly is huge and hard and I can't urinate"
+    regex:
+      - "can[']?t\\s+(urinat|pee|void)"
+      - "(urinary|bladder)\\s+retention"
+      - "(haven[']?t|hasn[']?t|not)\\s+(pee|urinate|gone)d?\\s+(since|in|for|all)"
+      - "nothing\\s+(comes?|came?)\\s+out"
+      - "(can[']?t|won[']?t|unable)\\s+(to\\s+)?(pee|urinate|go|void)"
+      - "(lower\\s+)?(bell?y|abdomen|stomach)\\s+(feel|is)s?\\s+(really\\s+)?(full|tight|swollen|bloated|pressurized)"
+      - "it\\s+won[']?t\\s+start"
+      - "can[']?t\\s+pee"
+      - "haven[']?t\\s+peed"
+      - "(haven[']?t|hasn[']?t|not).{0,10}(pee|urinat|void|gone).{0,10}(in\\s+)?(over\\s+)?(\\d+|twelve|eight|ten|six|twenty)\\s*(hour|hr)"
+      - "bladder.{0,10}(burst|explod|pop|about\\s+to)"
+      - "(complete|total)ly\\s+unable\\s+to\\s+(pee|urinat|void|go)"
+      - "need\\s+a\\s+catheter"
+      - "(belly|abdomen|stomach).{0,10}(huge|hard|distend|swollen).{0,15}(can[']?t|unable|won[']?t).{0,10}(pee|urinat|void)"
+      - "nothing.{0,10}(come|happen|start).{0,10}(out|when|no\\s+matter)"
+  medium:
+    phrases:
+      - "difficulty urinating"
+      - "very hard to urinate"
+      - "barely any urine output"
+      - "straining to urinate"
+      - "urinary retention symptoms"
+      - "not able to empty bladder"
+      - "only a few drops"
+      - "just a dribble"
+      - "a teaspoon and it stops"
+      - "body forgot what to do"
+      - "it burned a bit then nothing"
+      - "tiny dribble"
+      - "maybe a few drops then nothing"
+      - "I keep going to the bathroom but barely anything comes out"
+      - "feels like I need to go but I can't"
+      - "sitting on the toilet for twenty minutes and nothing"
+      - "running the water and it still won't come"
+      - "pushing as hard as I can and only drops come out"
+      - "stream starts and stops right away"
+      - "urine is just trickling"
+      - "had to push really hard just to get a little out"
+      - "my belly is so full and uncomfortable"
+      - "lower belly is really tight and I can't go"
+      - "had the catheter out and now I can't pee on my own"
+      - "since the anesthesia I can't pee right"
+      - "been trying to go all morning"
+      - "pressure down there like I have to go but nothing comes"
+      # --- MINIMIZER coverage ---
+      - "having a bit of trouble going"
+      - "stream isn't quite right"
+      - "just takes longer to get started"
+      - "probably just dehydrated"
+      - "not going as often as I should"
+      - "it's a bit uncomfortable down there"
+      - "can't quite empty my bladder"
+      - "peeing is a bit off"
+      # --- additional patterns ---
+      - "bladder hurts so bad"
+      - "painful pressure down there"
+      - "leaking but can't empty"
+      - "dribbling but feels full"
+      - "stomach is huge and tight"
+      - "since I started my new meds"
+      - "my retention is back"
+    regex:
+      - "(only|just|maybe)\\s+(a\\s+)?(few|tiny|little|couple)\\s+(drops?|dribble|trickle|bit)"
+      - "keep\\s+(going|running)\\s+(back\\s+)?(to\\s+)?the\\s+bathroom"
+      - "(body|it).*(won[']?t|forgot|refuse|doesn[']?t)\\s+(cooperate|work|go|start)"
+      - "(pee|urinat|void).*(barely|hardly|little|almost nothing)"
+      - "(strain|push|trying|sit).{0,20}(to\\s+)?(pee|urinate|void)"
+      - "can[']?t\\s+(pee|go)\\s+(normally|properly|right)"
+      - "feels?\\s+like\\s+I\\s+should\\s+be\\s+able\\s+to\\s+go"
+      - "lower\\s+(belly|back)\\s+(hurts?|pain|ache|tight)"
+      - "something[']?s\\s+off\\s+when\\s+I\\s+try\\s+to\\s+pee"
+      - "body\\s+won[']?t\\s+cooperate"
+      - "taking\\s+forever\\s+in.*bathroom"
+      - "trouble\\s+when\\s+I\\s+go\\s+to\\s+pee"
+      - "having\\s+trouble.*pee"
+      - "can[']?t\\s+go\\s+normally"
+      - "(lower\\s+)?(bell?y|abdomen).*(pressur|full|tight|bloat)"
+      - "not\\s+passing\\s+much"
+      - "can[']?t\\s+pee\\s+properly"
+      - "odd.*(not|aren[']?t)\\s+passing"
+      - "(uncomfortable|discomfort).*(down\\s+there|lower)"
+      - "(sit|sitting).{0,10}(on\\s+)?(the\\s+)?toilet.{0,10}(for\\s+)?(\\d+|twenty|thirty|fifteen|ten)\\s*(minute|min)"
+      - "(running|turn|ran).{0,10}(the\\s+)?(water|faucet|tap).{0,15}(still|won[']?t|can[']?t)"
+      - "stream.{0,10}(start|stop|weak|thin|slow|dribbl)"
+      - "(push|strain|bear).{0,10}(hard|down|really).{0,15}(drop|little|trickle|dribble)"
+      - "(catheter|cath).{0,10}(out|remov|taken).{0,15}(can[']?t|unable|won[']?t|not).{0,10}(pee|urinat|void|go)"
+      - "(anesthe|surgery|procedure|operation).{0,15}(can[']?t|unable|won[']?t).{0,10}(pee|urinat|void|go)"
+      - "(trying|been\\s+trying).{0,10}(to\\s+)?(go|pee|urinat).{0,10}(all\\s+)?(morning|day|night|afternoon|evening)"
+      - "pressure.{0,10}(down\\s+there|below|lower).{0,15}(have\\s+to\\s+go|need\\s+to\\s+go|nothing)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(just|only).{0,10}(a\\s+)?(little|bit|slight).{0,10}(trouble|hard|difficult).{0,10}(pee|urinat|go|void|empty)"
+      - "(probably|might be).{0,10}(just|nothing|dehydrat|normal).{0,20}(pee|urinat|bladder|go)"
+      - "(stream|flow|pee|urine).{0,15}(weak|slow|not quite|a bit|kind of|trickle|dribble|not right)"
+      - "(body|bladder).{0,15}(forgot|won't|not|can't).{0,10}(cooperat|work|go|empty|void|do)"
+      - "(can't\\s+quite|not\\s+really|having trouble).{0,15}(empty|void|go|pee|urinate|finish)"
+      # --- neurological cause ---
+      - "(back|spinal)\\s+(surgery|injury|problem)\\s+(and|now)\\s+(can'?t|unable|trouble)\\s+(pee|urinate|go)"
+      # --- medication cause ---
+      - "(started|new|changed)\\s+(my\\s+)?(meds?|medication|pills?).{0,20}(can'?t|trouble|unable|hard)\\s+(pee|urinat|void|go)"
+  low:
+    partials:
+      - "urinary retention"
+      - "blocked urine"
+      - "dribble"
+      - "belly full"
+      - "bladder pressure"
+      - "bathroom and nothing happens"
+      - "can't void"
+      - "weak stream"
+      - "slow stream"
+      - "hesitancy"
+      - "urinary difficulty"
+      - "straining"
+      - "incomplete emptying"
+      - "post-void fullness"
+
+negation_handling:
+  patterns:
+    - "urinating fine"
+    - "no urinary problems"
+    - "bladder emptying okay"
+    - "peeing normally"
+    - "urine flow is fine"
+    - "able to pee on my own now"
+    - "started peeing again"
+    - "bladder is emptying fine"
+    - "voiding without difficulty"
+    - "stream is back to normal"
+    - "peeing like normal"
+    - "no trouble urinating"
+    - "catheter is out and I am going fine"
+    - "went to the bathroom no problem"
+    - "urine output is good"
+    - "passing urine without issues"
+    - "no retention"
+    - "no difficulty voiding"
+    - "bladder feels empty after going"
+    - "just a little slow but it comes out fine"
+    # --- chronic back pain context (R1 scenarios) ---
+    - "chronic lower back"
+    - "chronic back pain"
+    - "chronic back"
+    - "lower back pain"
+    - "back pain for years"
+    - "back pain for months"
+    - "back pain for weeks"
+    - "back pain that"
+    - "back pain management"
+    - "physical therapy for my back"
+    - "PT for my back"
+    - "herniated disc"
+    - "bulging disc"
+    - "degenerative disc"
+    - "spinal stenosis"
+    - "sciatica"
+    - "my back has been"
+    - "back issue"
+    - "back problem"
+    - "back acting up"
+    - "my usual back"
+    # --- incontinence context (R1 post_procedure_incontinence) ---
+    - "leaking urine"
+    - "urine leakage"
+    - "incontinence"
+    - "leaking when I cough"
+    - "leaking when I sneeze"
+    - "leaking when I stand"
+    - "stress incontinence"
+    - "wearing pads"
+    - "pad changes"
+    - "leaking since surgery"
+    - "leaking since the procedure"
+    - "pelvic floor exercises"
+    - "pelvic floor"
+    - "Kegel"
+    - "kegels"
+    - "bladder control issue"
+  action: downgrade_confidence
diff --git a/list/taxonomy/worsening_chronic_pain/flows/clarify.yaml b/list/taxonomy/worsening_chronic_pain/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..e586691df6fb865e0ba5aef70f9cc8308c1d3134
--- /dev/null
+++ b/list/taxonomy/worsening_chronic_pain/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: worsening_chronic_pain
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: worsening_chronic_pain_clarify
+      goal: "Ask patient to describe their worsening chronic pain symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - worsening_chronic_pain_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/worsening_chronic_pain/flows/escalate_r1.yaml b/list/taxonomy/worsening_chronic_pain/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..813c766a9de4c68acc9619258055c2e49f61225b
--- /dev/null
+++ b/list/taxonomy/worsening_chronic_pain/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: worsening_chronic_pain
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/worsening_chronic_pain/flows/handoff.yaml b/list/taxonomy/worsening_chronic_pain/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..c842dcf28df38fbc513603d7d8f369da7c9e91ea
--- /dev/null
+++ b/list/taxonomy/worsening_chronic_pain/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: worsening_chronic_pain
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: worsening_chronic_pain_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: worsening_chronic_pain_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/worsening_chronic_pain/rules.yaml b/list/taxonomy/worsening_chronic_pain/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d476a43b4973a0646b79dc965af7217491142004
--- /dev/null
+++ b/list/taxonomy/worsening_chronic_pain/rules.yaml
@@ -0,0 +1,21 @@
+domain: worsening_chronic_pain
+target_risk_class: R1
+
+decision_rules:
+  - id: worsening_chronic_pain_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r1
+
+  - id: worsening_chronic_pain_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r1
+
+  - id: worsening_chronic_pain_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/worsening_chronic_pain/triggers.yaml b/list/taxonomy/worsening_chronic_pain/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d29243ac6ac203b8cf530a5f79e1fe5e22790a59
--- /dev/null
+++ b/list/taxonomy/worsening_chronic_pain/triggers.yaml
@@ -0,0 +1,34 @@
+domain: worsening_chronic_pain
+priority: 46
+
+lexical_signals:
+  high:
+    phrases:
+      - "chronic pain getting worse"
+      - "pain has been increasing steadily"
+      - "pain level going up despite treatment"
+      - "pain worse than before discharge"
+      - "chronic pain flare-up"
+      - "pain management not working anymore"
+    regex:
+      - "chronic\\s+pain.*(worse|increasing|flare)"
+      - "pain.*getting\\s+worse"
+  medium:
+    phrases:
+      - "pain is a bit worse than before"
+      - "more pain than usual"
+      - "pain seems to be increasing"
+      - "not getting relief from pain"
+      - "pain coming back stronger"
+  low:
+    partials:
+      - "pain worse"
+      - "chronic pain"
+      - "pain increasing"
+
+negation_handling:
+  patterns:
+    - "pain is better"
+    - "pain improving"
+    - "pain is manageable now"
+  action: downgrade_confidence
diff --git a/list/taxonomy/worsening_depression_si/flows/clarify.yaml b/list/taxonomy/worsening_depression_si/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5889331c1654d1933b787da3dbb240e8e2b64c7a
--- /dev/null
+++ b/list/taxonomy/worsening_depression_si/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: worsening_depression_si
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: worsening_depression_si_clarify
+      goal: "Ask patient to describe their worsening depression si symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - worsening_depression_si_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/worsening_depression_si/flows/escalate_r1.yaml b/list/taxonomy/worsening_depression_si/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..a1e43e4a9c9c50f4f36956de1d66269320acba9b
--- /dev/null
+++ b/list/taxonomy/worsening_depression_si/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: worsening_depression_si
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/worsening_depression_si/flows/escalate_r2.yaml b/list/taxonomy/worsening_depression_si/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..240e405c6e1a70c5e378352df47fabe0f7a90c80
--- /dev/null
+++ b/list/taxonomy/worsening_depression_si/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: worsening_depression_si
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will be connected to discuss their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "connect"
+        - "important"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: urgent
+    response_spec:
+      id: r2_handoff
+      goal: "Warm transfer to nurse with context summary"
+      tone: professional
+      must_include:
+        - "connecting"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/worsening_depression_si/flows/handoff.yaml b/list/taxonomy/worsening_depression_si/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..16f68679bb76c11c32121c9ea08414bc91543b36
--- /dev/null
+++ b/list/taxonomy/worsening_depression_si/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: worsening_depression_si
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: worsening_depression_si_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: worsening_depression_si_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/worsening_depression_si/rules.yaml b/list/taxonomy/worsening_depression_si/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5884530ecb6eab28e4d43cf87fa42c7966bc75da
--- /dev/null
+++ b/list/taxonomy/worsening_depression_si/rules.yaml
@@ -0,0 +1,27 @@
+domain: worsening_depression_si
+target_risk_class: R2
+
+decision_rules:
+  - id: worsening_depression_si_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r2
+
+  - id: worsening_depression_si_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r2
+
+  - id: worsening_depression_si_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: worsening_depression_si_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/worsening_depression_si/triggers.yaml b/list/taxonomy/worsening_depression_si/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..5859c6a2104ce94ded6c8245cba520f66143c6d6
--- /dev/null
+++ b/list/taxonomy/worsening_depression_si/triggers.yaml
@@ -0,0 +1,423 @@
+domain: worsening_depression_si
+priority: 50
+
+lexical_signals:
+  high:
+    phrases:
+      # --- ORIGINAL ---
+      - "feeling more depressed and having dark thoughts"
+      - "depression getting worse and thinking about death"
+      - "can't stop thinking about not being here"
+      - "worsening depression with thoughts of death"
+      - "depression worsening and feeling hopeless about life"
+      - "I don't see the point anymore"
+      - "feeling like giving up"
+      - "thoughts about ending things"
+      - "don't want to go on"
+      - "feeling worthless and hopeless"
+      - "crying all the time and can't cope"
+      - "much more depressed since coming home"
+      # --- EXPANDED naturalistic ---
+      - "what's the point of anything"
+      - "I don't care if I wake up tomorrow"
+      - "everything feels pointless"
+      - "I just want this to be over"
+      - "wish I could go to sleep and not wake up"
+      - "nobody would miss me"
+      - "everyone would be better off without me"
+      - "I can't do this anymore"
+      - "I'm done trying"
+      - "nothing matters anymore"
+      - "I feel completely empty inside"
+      - "I've been having really dark thoughts"
+      - "thinking about hurting myself"
+      - "I don't want to be here anymore"
+      - "I have no reason to keep going"
+      - "life isn't worth living"
+      - "I feel dead inside"
+    regex:
+      # --- ORIGINAL ---
+      - "(depression|depressed).*(worse|worsening|dark\\s+thoughts|getting\\s+bad)"
+      - "thinking\\s+about\\s+(death|not\\s+being|ending)"
+      - "(don'?t|no)\\s+(see\\s+the\\s+point|want\\s+to\\s+(go|live|be))"
+      - "(giving|give)\\s+up"
+      - "(hopeless|worthless)\\s+(and|about)"
+      # --- EXPANDED ---
+      - "what'?s\\s+the\\s+point"
+      - "(wish|want).{0,15}(not\\s+wake|go\\s+to\\s+sleep\\s+and\\s+not|disappear|die)"
+      - "(nobody|no\\s+one).{0,15}(miss|care|notice)"
+      - "better\\s+off\\s+without\\s+me"
+      - "(can'?t|cannot)\\s+(do\\s+this|take\\s+(it|this)|go\\s+on|keep\\s+going)"
+      - "done\\s+(with\\s+)?(everything|trying|life|all\\s+(of\\s+)?this)"
+      - "nothing\\s+(matters|is\\s+worth|feels\\s+real)"
+      - "(completely|totally|just)\\s+(empty|numb|hollow)"
+      - "(really|very)\\s+dark\\s+thoughts"
+      - "(hurting|harming)\\s+(myself|me)"
+      - "don'?t\\s+want\\s+to\\s+be\\s+here"
+      - "no\\s+reason\\s+to\\s+(keep|continue|go)"
+      - "(life|living).{0,15}(not\\s+worth|pointless|meaningless)"
+      - "dead\\s+inside"
+      - "(feel|feeling)\\s+like\\s+(a\\s+burden|giving\\s+up|I'?m\\s+a\\s+burden)"
+  medium:
+    phrases:
+      # --- ORIGINAL ---
+      - "feeling more depressed"
+      - "depression is getting worse"
+      - "mood getting darker"
+      - "struggling with dark thoughts"
+      - "not wanting to get out of bed"
+      - "mental health declining"
+      - "feeling really down"
+      - "more depressed than before"
+      - "can't stop crying"
+      - "nothing makes me happy"
+      - "lost interest in everything"
+      - "feeling hopeless"
+      - "really struggling emotionally"
+      - "mood is really low"
+      # --- EXPANDED naturalistic ---
+      - "everything feels heavy"
+      - "I'm just going through the motions"
+      - "I don't care anymore"
+      - "been staying in bed all day"
+      - "not eating much"
+      - "stopped doing things I used to enjoy"
+      - "don't want to talk to anyone"
+      - "isolating myself"
+      - "can't get out of bed"
+      - "haven't showered in days"
+      - "stopped answering the phone"
+      - "I just sit and stare at the wall"
+      - "I don't feel anything"
+      - "haven't left the house in days"
+      - "I stopped caring about everything"
+      - "lost motivation to do anything"
+      - "I can't even make myself eat"
+      - "just want to be alone all the time"
+      - "no energy for anything"
+      - "I feel like a burden"
+      - "everything just feels gray"
+      - "I don't enjoy anything anymore"
+      - "feel like I'm drowning"
+      - "I'm not sleeping at all"
+      - "sleeping all day and still tired"
+      - "my mood is a lot worse since I left the hospital"
+      - "I feel so much worse than before discharge"
+      - "I've been really struggling since I came home"
+      - "getting worse not better"
+      - "I cry for no reason"
+      - "the sadness won't go away"
+      - "constantly on the verge of tears"
+      # --- MINIMIZER coverage ---
+      - "I'm fine, just tired"
+      - "everybody feels down sometimes"
+      - "it's nothing, don't worry about me"
+      - "just a little down I guess"
+      - "probably just the weather"
+      - "not a big deal, just not myself"
+      - "I'm managing, just not great"
+      - "been a bit low but it's probably nothing"
+      - "just haven't felt like doing much"
+      - "I'm okay, just a rough patch"
+      - "don't want to make a big deal out of it"
+      # --- Indirect language patterns (R2 recall) ---
+      - "things have been harder"
+      - "things have been harder lately"
+      - "it's been getting worse"
+      - "getting worse lately"
+      - "not myself lately"
+      - "haven't been myself"
+      - "just not myself"
+      - "harder to get through the day"
+      - "harder to keep going"
+      # --- RED_HERRING / buried mood change ---
+      - "also my mood has been"
+      - "and I guess my mood"
+      - "oh and I've been kind of down"
+      - "by the way I've been feeling"
+      # --- additional functional decline ---
+      - "haven't gotten dressed in days"
+      - "house is a disaster and I don't care"
+      - "stopped taking my medications"
+      # --- Phase 6: R2 recall expansion ---
+      - "feeling worse than before"
+      - "things are getting darker"
+      - "can't see the point"
+      - "nothing helps anymore"
+      - "medications stopped working"
+      - "therapist is worried"
+      # --- Phase 7: Worsening language ---
+      - "getting worse"
+      - "getting so much worse"
+      - "getting harder"
+      - "harder to function"
+      - "more depressed"
+      - "more depressed than usual"
+      - "depression has gotten worse"
+      - "depression has gotten so much worse"
+      - "been really struggling"
+      - "really struggling lately"
+      - "struggling the last few weeks"
+      - "struggling the last couple weeks"
+      - "it's been getting worse"
+      - "things have been getting worse"
+      - "mood has been getting worse"
+      # --- Phase 7: Medication concerns ---
+      - "meds not working"
+      - "meds aren't working"
+      - "medication not working"
+      - "medication isn't working"
+      - "antidepressant not working"
+      - "antidepressant isn't working"
+      - "need to adjust my medication"
+      - "need to adjust my meds"
+      - "side effects are bad"
+      - "side effects are worse"
+      - "missed my medication"
+      - "missed doses"
+      - "might've missed doses"
+      - "haven't been taking my medication"
+      - "stopped taking my meds"
+      # --- Phase 7: Functional decline ---
+      - "can't get out of bed"
+      - "barely get out of bed"
+      - "can barely get out of bed"
+      - "hard to get out of bed"
+      - "stopped doing things"
+      - "stopped doing things I enjoy"
+      - "stopped going out"
+      - "isolating myself"
+      - "been isolating"
+      - "withdrawing from people"
+      - "can't focus at work"
+      - "can't concentrate"
+      - "called out of work"
+      - "called out twice"
+      - "not functioning"
+      - "barely functioning"
+      - "going through the motions"
+      - "just going through the motions"
+      # --- Phase 7: Indirect SI hints ---
+      - "dark thoughts"
+      - "really dark thoughts"
+      - "scary thoughts"
+      - "really scary thoughts"
+      - "having scary thoughts"
+      - "having dark thoughts"
+      - "feeling hopeless"
+      - "completely hopeless"
+      - "don't see the point"
+      - "what's the point"
+      - "I don't see the point anymore"
+      - "there's no point"
+      - "imagining not being here"
+      - "not wanting to be here"
+      - "what if I wasn't around"
+      - "what if I just wasn't around"
+      - "easier if I didn't wake up"
+      - "don't want to wake up"
+      - "thinking about not being here"
+      - "I can't keep doing this"
+      - "can't do this anymore"
+      - "intrusive thoughts"
+      - "intrusive what if thoughts"
+      - "thoughts pop in"
+      - "thoughts keep coming"
+      - "brain is pitching an exit"
+      - "what if I just disappeared"
+      # --- Phase 7: Caregiver concerns ---
+      - "worried about him"
+      - "worried about her"
+      - "really worried about him"
+      - "really worried about her"
+      - "she's not herself"
+      - "he's not himself"
+      - "she hasn't been herself"
+      - "he hasn't been himself"
+      - "concerned about my son"
+      - "concerned about my daughter"
+      - "concerned about my husband"
+      - "concerned about my wife"
+      - "scared for her"
+      - "scared for him"
+      - "something's wrong with him"
+      - "something's wrong with her"
+    regex:
+      # --- EXPANDED ---
+      - "everything\\s+(feels?|is)\\s+(heavy|dark|gray|pointless|hopeless|empty)"
+      - "(just|only)\\s+going\\s+through\\s+the\\s+motions"
+      - "don'?t\\s+care\\s+(about\\s+)?(anything|anymore|any\\s+of)"
+      - "(stayed?|staying|been)\\s+in\\s+bed\\s+(all|the\\s+whole|most\\s+of\\s+the)"
+      - "(not|haven'?t\\s+been|stopped|quit|can'?t)\\s+(eat|sleep|shower|cook|clean)"
+      - "stopped\\s+(doing|going|seeing|talking|caring|answering|leaving)"
+      - "don'?t\\s+want\\s+to\\s+(talk|see\\s+anyone|be\\s+around|leave|go\\s+out)"
+      - "(isolat|withdraw|pulling\\s+away|cutting\\s+(myself|everyone)\\s+off)"
+      - "haven'?t\\s+(left|showered|eaten|slept|gotten\\s+out)"
+      - "(no|zero|lost|don'?t\\s+have)\\s+(energy|motivation|interest|desire|appetite)"
+      - "(feel|feeling|felt)\\s+like\\s+(a\\s+burden|I'?m\\s+drowning|I'?m\\s+sinking)"
+      - "(mood|depression|mental\\s+health).{0,15}(worse|declining|spiraling|tanking)"
+      - "(cry|crying|tears).{0,15}(all\\s+the\\s+time|constantly|for\\s+no\\s+reason|won'?t\\s+stop)"
+      - "(sleep|sleeping)\\s+(all\\s+day|too\\s+much|not\\s+at\\s+all|barely|can'?t)"
+      - "(sadness|emptiness|darkness).{0,15}(won'?t|doesn'?t|never)\\s+(go\\s+away|stop|end|lift)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(just|only).{0,10}(a\\s+)?(little|bit|rough).{0,10}(down|low|off|tired|sad|blue)"
+      - "(fine|okay|managing|alright).{0,10}(just|but).{0,15}(tired|not great|not myself|rough|low|down)"
+      - "(probably|might be).{0,10}(just|nothing|normal|weather|stress|tired|adjustment)"
+      - "(don'?t|didn'?t).{0,10}(want|mean).{0,10}(to|make).{0,10}(big deal|worry|bother|burden)"
+      - "(everybody|everyone|people).{0,15}(feels?|gets?|goes?\\s+through).{0,10}(down|low|this|rough)"
+      # --- Phase 6: R2 recall expansion ---
+      - "(feeling|feel).{0,20}(worse|lower|darker|emptier).{0,20}(than|lately|recently)"
+      - "(can't|cannot).{0,15}(see|find).{0,15}(point|reason|purpose)"
+      - "(nothing|medication|meds|therapy).{0,20}(help|work|helping|working).{0,10}(anymore)?"
+      - "(therapist|counselor|doctor).{0,20}(worried|concerned|wants me to call)"
+      # --- Phase 7: Worsening language regex ---
+      - "(depression|mood|mental\\s+health).{0,20}(getting|gotten|became|has\\s+been).{0,15}(worse|bad|harder)"
+      - "(struggling|really\\s+struggling).{0,20}(lately|recently|the\\s+last|past\\s+few)"
+      - "(it'?s|things).{0,15}(been|getting).{0,15}(worse|harder|bad)"
+      # --- Phase 7: Medication concern regex ---
+      - "(meds?|medication|antidepressant).{0,20}(not|isn'?t|aren'?t|stopped).{0,10}(working|helping)"
+      - "(need\\s+to|should|have\\s+to).{0,15}(adjust|change|switch).{0,15}(med|medication|dose)"
+      - "(missed|skipped|haven'?t\\s+been\\s+taking).{0,15}(dose|medication|meds|pills)"
+      # --- Phase 7: Functional decline regex ---
+      - "(can'?t|barely|hard\\s+to|struggle\\s+to).{0,15}(get\\s+out\\s+of\\s+bed|function|focus|concentrate)"
+      - "(stopped|quit|haven'?t\\s+been).{0,15}(doing\\s+things|going\\s+out|seeing\\s+people|leaving)"
+      - "(called|calling).{0,10}(out|in\\s+sick|off).{0,10}(of\\s+work|from\\s+work|twice|again)"
+      - "(isolating|withdrawing|pulling\\s+away|cutting\\s+off)"
+      # --- Phase 7: Indirect SI regex ---
+      - "(dark|scary|intrusive).{0,10}(thoughts|ideas|feelings)"
+      - "(don'?t|can'?t).{0,15}(see|find).{0,10}(the\\s+)?point"
+      - "(imagining|thinking\\s+about|wondering\\s+about).{0,15}(not\\s+being|disappearing|not\\s+existing)"
+      - "what.{0,10}if.{0,15}(wasn'?t|weren'?t|I\\s+just).{0,10}(around|here)"
+      - "(easier|better).{0,10}if.{0,10}(I\\s+)?didn'?t.{0,10}wake"
+      - "(can'?t|cannot).{0,10}(keep\\s+)?doing\\s+this"
+      - "brain.{0,15}(pitching|suggesting|showing).{0,10}(an\\s+)?exit"
+      # --- Phase 7: Caregiver concern regex ---
+      - "(worried|concerned|scared).{0,15}(about|for).{0,15}(him|her|my\\s+(son|daughter|husband|wife|partner|mom|dad))"
+      - "(she|he).{0,10}(is|has)n'?t.{0,10}(been\\s+)?her(self)?|him(self)?"
+      - "something.{0,10}(is\\s+)?wrong.{0,10}with.{0,10}(him|her|my)"
+    partials:
+      - "going through the motions"
+      - "no motivation"
+      - "no energy"
+      - "isolating"
+      - "withdrawing"
+  low:
+    partials:
+      # --- ORIGINAL ---
+      - "depressed"
+      - "depression worsening"
+      - "dark thoughts"
+      - "hopeless"
+      - "feeling down"
+      - "mood low"
+      - "emotionally struggling"
+      # --- EXPANDED ---
+      - "mood worse"
+      - "anhedonia"
+      - "loss of interest"
+      - "not myself"
+      - "not eating"
+      - "not sleeping"
+      - "staying in bed"
+      - "crying a lot"
+      - "no appetite"
+      - "feel empty"
+      - "feel numb"
+      - "feel worthless"
+      - "apathetic"
+      - "no pleasure"
+      - "sad all the time"
+      - "can't cope"
+      - "mental health"
+      - "suicidal"
+      - "self-harm"
+
+negation_handling:
+  patterns:
+    # --- ORIGINAL ---
+    - "not having dark thoughts"
+    - "depression stable"
+    - "mood improving"
+    # --- EXPANDED ---
+    - "no dark thoughts"
+    - "no thoughts of hurting myself"
+    - "no suicidal thoughts"
+    - "no thoughts of self-harm"
+    - "not suicidal"
+    - "depression is better"
+    - "depression is manageable"
+    - "mood is stable"
+    - "mood is improving"
+    - "mood is better"
+    - "feeling better emotionally"
+    - "mental health is improving"
+    - "started feeling better"
+    - "mood lifted"
+    - "getting out of bed more"
+    - "started eating again"
+    - "sleeping better"
+    - "enjoying things again"
+    - "depression under control"
+    - "no longer having dark thoughts"
+    - "dark thoughts have stopped"
+    - "doing better mentally"
+    - "feeling more like myself"
+    - "more motivated"
+    - "therapy is helping"
+    - "medication is helping"
+    - "antidepressant is working"
+    # --- non-depression context (R1 scenarios) ---
+    - "probably just a routine"
+    - "probably just need a checkup"
+    - "probably nothing serious"
+    - "probably just routine"
+    - "probably just need to"
+    - "probably just normal"
+    - "not eating much since surgery"
+    - "not eating well since the procedure"
+    - "appetite has been poor"
+    - "appetite issue"
+    - "poor oral intake"
+    - "not sleeping because of"
+    - "not sleeping due to"
+    - "not sleeping because I keep"
+    - "scheduling an appointment"
+    - "booking an appointment"
+    - "nothing urgent"
+    - "not an emergency"
+    - "calling about my appointment"
+    - "calling about scheduling"
+    - "calling about my medication"
+    - "calling about my wound"
+    - "calling about my incision"
+    - "calling about my follow-up"
+    - "leaking urine"
+    - "urine leakage"
+    - "incontinence"
+    - "bladder control"
+    - "pelvic floor"
+    - "wearing pads"
+    # --- polite scheduling / politeness disclaimers ---
+    - "don't want to be a bother"
+    - "don't want to be picky"
+    - "don't want to be too early"
+    - "don't want to be too late"
+    - "don't want to be difficult"
+    - "don't want to be annoying"
+    - "don't want to be in the way"
+    - "don't want to be rude"
+    - "don't want to be demanding"
+    - "don't want to take up"
+    - "don't want to overcomplicate"
+    - "don't want to make this more"
+    - "don't want to make a big production"
+    - "don't want to be a burden on the schedule"
+    - "probably nothing"
+    - "probably just a general"
+    - "probably just a check"
+    - "probably just need"
+    - "scheduling"
+    - "schedule an appointment"
+    - "make an appointment"
+    - "need to schedule"
+  action: downgrade_confidence
diff --git a/list/taxonomy/wound_concern/flows/clarify.yaml b/list/taxonomy/wound_concern/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..8979317561ef7da921772b3a24a5976ec346bd0d
--- /dev/null
+++ b/list/taxonomy/wound_concern/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: wound_concern
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: wound_concern_clarify
+      goal: "Ask patient to describe their wound concern symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - wound_concern_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/wound_concern/flows/escalate_r1.yaml b/list/taxonomy/wound_concern/flows/escalate_r1.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ed217cfc592e5dfa0d6e04eb691f84c3c7aa7cbf
--- /dev/null
+++ b/list/taxonomy/wound_concern/flows/escalate_r1.yaml
@@ -0,0 +1,23 @@
+flow_id: escalate_r1
+type: escalation
+domain: wound_concern
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r1_escalation_notice
+      goal: "Inform patient their care team will be notified and will follow up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "guarantee"
+        - "nothing to worry about"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/wound_concern/flows/handoff.yaml b/list/taxonomy/wound_concern/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..50263f6c91d358edccb8b1757d92100c184fb81b
--- /dev/null
+++ b/list/taxonomy/wound_concern/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: wound_concern
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: wound_concern_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: wound_concern_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/wound_concern/rules.yaml b/list/taxonomy/wound_concern/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..70929a881cced28b1f83160a8d5ffb02aeaa12e6
--- /dev/null
+++ b/list/taxonomy/wound_concern/rules.yaml
@@ -0,0 +1,21 @@
+domain: wound_concern
+target_risk_class: R1
+
+decision_rules:
+  - id: wound_concern_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: escalate_r1
+
+  - id: wound_concern_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: escalate_r1
+
+  - id: wound_concern_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
diff --git a/list/taxonomy/wound_concern/triggers.yaml b/list/taxonomy/wound_concern/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3cf2e90f3aa51545efc1c078be75fe67f13c4ab2
--- /dev/null
+++ b/list/taxonomy/wound_concern/triggers.yaml
@@ -0,0 +1,34 @@
+domain: wound_concern
+priority: 44
+
+lexical_signals:
+  high:
+    phrases:
+      - "wound looks red around the edges"
+      - "drainage from incision site"
+      - "wound not healing right"
+      - "incision site is sore and red"
+      - "new redness around surgical site"
+      - "wound has changed color"
+    regex:
+      - "wound.*(red|drain|not\\s+healing)"
+      - "incision.*(red|sore|drain)"
+  medium:
+    phrases:
+      - "wound looks different than before"
+      - "some redness near wound"
+      - "slight drainage from wound"
+      - "incision area is tender"
+      - "wound changed appearance"
+  low:
+    partials:
+      - "wound concern"
+      - "incision redness"
+      - "wound appearance"
+
+negation_handling:
+  patterns:
+    - "wound looks good"
+    - "healing well"
+    - "incision is fine"
+  action: downgrade_confidence
diff --git a/list/taxonomy/wound_infection/flows/clarify.yaml b/list/taxonomy/wound_infection/flows/clarify.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7df4a704b7eb70468990c3bf29abd68a3624b4e2
--- /dev/null
+++ b/list/taxonomy/wound_infection/flows/clarify.yaml
@@ -0,0 +1,25 @@
+flow_id: clarify
+type: clarification
+domain: wound_infection
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: wound_infection_clarify
+      goal: "Ask patient to describe their wound infection symptom more specifically"
+      tone: gentle_professional
+      must_include:
+        - "tell me more"
+      must_ask:
+        - "describe"
+      must_not:
+        - "diagnos"
+        - "don't worry"
+      max_questions: 1
+    collects:
+      - wound_infection_description
+
+exit:
+  on_complete: re_evaluate
+  on_unclear: handoff
diff --git a/list/taxonomy/wound_infection/flows/escalate_r2.yaml b/list/taxonomy/wound_infection/flows/escalate_r2.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ecd004d2c536efff417e677e1d5888a75e43e2fe
--- /dev/null
+++ b/list/taxonomy/wound_infection/flows/escalate_r2.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r2
+type: escalation
+domain: wound_infection
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: r2_escalation_notice
+      goal: "Inform patient a nurse will follow up same day about their symptoms"
+      tone: calm_reassuring
+      must_include:
+        - "nurse"
+        - "follow up"
+        - "same day"
+      must_ask: []
+      must_not:
+        - "diagnos"
+        - "don't worry"
+        - "probably"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: clinical_nurse
+    urgency: same_day
+    response_spec:
+      id: r2_handoff
+      goal: "Schedule same-day nurse callback with context summary"
+      tone: professional
+      must_include:
+        - "follow up"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/wound_infection/flows/escalate_r3.yaml b/list/taxonomy/wound_infection/flows/escalate_r3.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..0064fba7ce2886fccd91b9d78b57bc440d853188
--- /dev/null
+++ b/list/taxonomy/wound_infection/flows/escalate_r3.yaml
@@ -0,0 +1,37 @@
+flow_id: escalate_r3
+type: escalation
+domain: wound_infection
+actions:
+- step: 1
+  type: respond
+  response_spec:
+    id: r3_escalation_notice
+    goal: Instruct patient to call 911 immediately and inform them of nurse transfer
+    tone: calm_direct
+    must_include:
+    - call 911
+    - right away
+    must_ask: []
+    must_not:
+    - diagnos
+    - don't worry
+    - probably
+    - based on what you
+    - I've determined
+    - my assessment
+    max_questions: 0
+- step: 2
+  type: handoff
+  target: clinical_nurse
+  urgency: immediate
+  response_spec:
+    id: r3_handoff
+    goal: Transfer to clinical nurse with context summary
+    tone: professional
+    must_include:
+    - transferring
+    must_ask: []
+    must_not:
+    - goodbye
+exit:
+  on_complete: end
diff --git a/list/taxonomy/wound_infection/flows/handoff.yaml b/list/taxonomy/wound_infection/flows/handoff.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..fcb8fc2a5a433e6d77282ec3af664bc79b553f93
--- /dev/null
+++ b/list/taxonomy/wound_infection/flows/handoff.yaml
@@ -0,0 +1,34 @@
+flow_id: handoff
+type: handoff
+domain: wound_infection
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: wound_infection_handoff
+      goal: "Let patient know they will be connected with someone who can help"
+      tone: warm_professional
+      must_include:
+        - "connect"
+        - "help"
+      must_ask: []
+      must_not:
+        - "goodbye"
+      max_questions: 0
+
+  - step: 2
+    type: handoff
+    target: general_nurse_line
+    urgency: normal
+    response_spec:
+      id: wound_infection_handoff_transfer
+      goal: "Transfer to general nurse line"
+      tone: professional
+      must_include:
+        - "transferring"
+      must_ask: []
+      must_not: []
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/wound_infection/flows/reassure_low_risk.yaml b/list/taxonomy/wound_infection/flows/reassure_low_risk.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..41826a699846916f20ec81d641f3445e942342d5
--- /dev/null
+++ b/list/taxonomy/wound_infection/flows/reassure_low_risk.yaml
@@ -0,0 +1,21 @@
+flow_id: reassure_low_risk
+type: resolution
+domain: wound_infection
+
+actions:
+  - step: 1
+    type: respond
+    response_spec:
+      id: wound_infection_reassure
+      goal: "Acknowledge the patient's concern about their wound, note that their care team will be informed for routine follow-up"
+      tone: warm_professional
+      must_include:
+        - "care team"
+        - "follow up"
+      must_not:
+        - "emergency"
+        - "don't worry"
+      max_questions: 0
+
+exit:
+  on_complete: end
diff --git a/list/taxonomy/wound_infection/flows/safety_screen.yaml b/list/taxonomy/wound_infection/flows/safety_screen.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..987b664caea8772202e7df77f626bcedd8fb0e70
--- /dev/null
+++ b/list/taxonomy/wound_infection/flows/safety_screen.yaml
@@ -0,0 +1,55 @@
+flow_id: safety_screen
+type: screening
+domain: wound_infection
+
+required_slots:
+  - fever_present
+  - wound_systemic_signs
+  - wound_drainage_change
+  - wound_redness_spreading
+
+actions:
+  - step: 1
+    type: ask
+    response_spec:
+      id: wound_infection_screen_step1
+      goal: "Gather details about wound appearance and any changes in drainage"
+      tone: calm_urgent
+      must_include:
+        - "wound"
+      must_ask:
+        - "Has the redness around your wound been spreading or getting worse?"
+        - "Have you noticed any change in drainage — more fluid, pus, or a bad smell?"
+      must_not:
+        - "don't worry"
+        - "probably nothing"
+      max_questions: 2
+    collects:
+      - wound_redness_spreading
+      - wound_drainage_change
+
+  - step: 2
+    type: ask
+    response_spec:
+      id: wound_infection_screen_step2
+      goal: "Screen for systemic infection signs"
+      tone: calm_urgent
+      must_include:
+        - "also"
+      must_ask:
+        - "Do you have a fever or feel feverish?"
+        - "Are you feeling chills, body aches, or generally unwell?"
+      must_not:
+        - "don't worry"
+        - "probably fine"
+      max_questions: 2
+    collects:
+      - fever_present
+      - wound_systemic_signs
+
+exit:
+  on_complete: evaluate_risk
+  on_r3: escalate_r3
+  on_r2: escalate_r2
+  on_low_risk: reassure_low_risk
+  on_unclear: escalate_r3
diff --git a/list/taxonomy/wound_infection/rules.yaml b/list/taxonomy/wound_infection/rules.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..82a2977a76ec30741a92cddca1bce5eb34fc3c9f
--- /dev/null
+++ b/list/taxonomy/wound_infection/rules.yaml
@@ -0,0 +1,33 @@
+domain: wound_infection
+target_risk_class: R2
+
+decision_rules:
+  - id: wound_infection_high_confidence
+    if:
+      confidence: high
+    then:
+      flow: safety_screen
+
+  - id: wound_infection_medium_confidence
+    if:
+      confidence: medium
+    then:
+      flow: safety_screen
+
+  - id: wound_infection_low_confidence
+    if:
+      confidence: low
+    then:
+      flow: clarify
+
+  - id: wound_infection_r3_escalation
+    if:
+      risk_class: R3
+    then:
+      flow: escalate_r3
+
+  - id: wound_infection_r2_escalation
+    if:
+      risk_class: R2
+    then:
+      flow: escalate_r2
diff --git a/list/taxonomy/wound_infection/triggers.yaml b/list/taxonomy/wound_infection/triggers.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..459a5be02d54ae0ca8a5e71a100fa40000210b6d
--- /dev/null
+++ b/list/taxonomy/wound_infection/triggers.yaml
@@ -0,0 +1,301 @@
+domain: wound_infection
+priority: 72
+
+lexical_signals:
+  high:
+    phrases:
+      - "wound is red and oozing pus"
+      - "incision looks infected"
+      - "surgical site infection"
+      - "wound dehiscence"
+      - "incision is opening up"
+      - "wound smells bad and is draining"
+      - "leaking yellowish gunk"
+      - "started oozing"
+      - "red streaks from the wound"
+      - "cut is getting infected"
+      - "pus is coming out of my incision"
+      - "green drainage from the wound"
+      - "wound is oozing thick yellow stuff"
+      - "my surgical wound opened up and is draining"
+      - "red streaks going up my arm from the cut"
+      - "wound has a foul smell"
+      - "incision is separating and leaking"
+      - "fever and my wound looks terrible"
+      - "abscess forming near the wound"
+      - "wound site is hot red and swollen"
+      - "cloudy discharge from the incision"
+      - "cellulitis around the wound"
+      - "the stitches area is oozing greenish stuff"
+      - "my wound is weeping and smells rotten"
+    regex:
+      - "(wound|incision|cut|scrape)\\s+(infect|dehisc|opening)"
+      - "surgical\\s+site\\s+infection"
+      - "(wound|cut|incision|scrape).*(ooz|pus|yellow|green|gunk|stink|smell)"
+      - "(red\\s+streak|streaks?\\s+from).*(wound|cut|incision|scrape)"
+      - "(wound|cut|incision|scrape).*(leak|drain).*(yellow|green|pus|gunk)"
+      - "(wound|incision|cut|surgical\\s+site).*(foul|rotten|terrible|awful)\\s+(smell|odor)"
+      - "(pus|abscess|cellulitis).*(wound|incision|cut|surgical)"
+      - "(wound|incision|cut).*(open|separat|split|gap|came\\s+apart)"
+      - "(?<!no )(?<!not )fever.*(wound|incision|cut|surgical)"
+      - "(wound|incision|cut|surgical).*(?<!no )(?<!not )(fever|chills)"
+      - "(thick|cloudy|milky).*(discharge|drainage|fluid).*(wound|incision|cut)"
+      - "(wound|incision|cut).*(thick|cloudy|milky).*(discharge|drainage|fluid)"
+      - "red.{0,15}(streak|line).{0,15}(from|near|around).{0,15}(wound|cut|incision|stitch)"
+      - "(stitch|suture|staple).{0,20}(area|site).{0,20}(ooz|drain|pus|infect|open)"
+  medium:
+    phrases:
+      - "wound is red and swollen"
+      - "incision site looks worse"
+      - "pus coming from wound"
+      - "wound is hot to touch"
+      - "surgical wound not healing"
+      - "drainage from incision"
+      - "cut is acting up"
+      - "scrape is acting weird"
+      - "looks more angry"
+      - "redder and a bit swollen"
+      - "kind of shiny around the edges"
+      - "wound thing"
+      - "hurts more than yesterday"
+      - "it smells bad"
+      - "doing this gross stuff"
+      - "not looking like a normal scab"
+      - "skin looks a bit more red"
+      - "wound is warm when I touch it"
+      - "the area around my stitches is puffy"
+      - "my incision is not looking right"
+      - "wound seems to be getting bigger"
+      - "more swollen than it was yesterday"
+      - "it keeps weeping clear fluid"
+      - "drainage soaking through the bandage"
+      - "the skin around the wound is hard and red"
+      - "my cut is throbbing"
+      - "wound area feels tight and hot"
+      - "it was healing fine but now it looks worse"
+      - "the edges of the wound are puffy and red"
+      - "I changed the bandage and it looked gross"
+      - "there is stuff coming out of my wound"
+      - "wound is tender and warm"
+      - "the scab came off and underneath looks bad"
+      - "fever since the surgery"
+      - "running a temperature and my wound hurts"
+      # --- MINIMIZER coverage ---
+      - "incision site is just a little irritated"
+      - "probably nothing serious, just some redness"
+      - "maybe it looks a bit more red but that's probably just healing"
+      - "there's always been some wetness I think"
+      - "it looked yellowish and kind of thicker"
+      - "probably just part of healing"
+      - "wound isn't that bad, just a little sore"
+      - "just wanted to check, probably fine"
+      - "I caught a weird smell but I'm sure it's nothing"
+      - "bandage gets a bit damp"
+      - "maybe a little warmer than normal around the wound"
+    regex:
+      - "(wound|cut|incision|scrape).{0,30}(acting|look).{0,15}(up|weird|worse|angry|bad|off|gross)"
+      - "(wound|cut|incision|scrape).{0,30}(red|swollen|puffy|warm|hot|sore)"
+      - "(wound|cut|incision|scrape).{0,30}(not\\s+heal|won't\\s+heal|still)"
+      - "(redder|more\\s+red|more\\s+swollen|puffier|angrier).*than\\s+(yesterday|before|last)"
+      - "(cut|wound|scrape|incision).*(few|couple)\\s+days?.*(acting|look|worse|weird)"
+      - "(arm|leg|wrist|hand|knee|finger|shin|foot).*(acting\\s+weird|doing.*gross)"
+      - "shouldn't\\s+still\\s+be\\s+doing\\s+this"
+      - "(nicked|scraped|cut)\\s+(my|him)self.*(annoying|weird|acting)"
+      - "cut.{0,40}(getting|is).{0,20}(weird|worse|gross|infected)"
+      - "gunk\\s+(coming|com[ei]s?)\\s+(out|from)\\s+(of\\s+)?(a\\s+)?(cut|wound|scrape)"
+      - "scrape.*(few|couple)\\s+days.*(annoying|weird|acting|being)"
+      - "something\\s+on\\s+my\\s+skin.*(worry|worri|concern|bother)"
+      - "(wound|incision|cut).*(soak|soaking|bleed).*bandage"
+      - "(wound|incision|cut).*(bigger|spread|expand|widen)"
+      - "bandage.*(soak|soaking|yellow|green|smell)"
+      - "(stitch|suture|staple).{0,30}(puffy|red|swollen|warm|sore)"
+      - "(healing|healed).*(fine|good|well)\\s+(but|then|until)"
+      - "(?<!no )(?<!not )(fever|temperature|chills).*(surgery|procedure|operation)"
+      - "(surgery|procedure|operation).*(?<!no )(?<!not )(fever|temperature|chills)"
+      - "(wound|cut|incision).*(throb|pulse|pound)"
+      - "edges?.*(wound|cut|incision).*(puffy|red|swollen|raised)"
+      - "(wound|cut|incision).*(tight|hard|indurat).*(hot|warm|red)"
+      # --- MINIMIZER / CONFUSED_VAGUE coverage ---
+      - "(wound|cut|incision|scrape).{0,15}(just|only).{0,10}(a\\s+)?(little|bit|slight).{0,10}(irritat|red|sore|warm|tender|swollen)"
+      - "(probably|might be).{0,10}(just|nothing|normal|fine|healing).{0,20}(wound|cut|incision|red|sore)"
+      - "(wound|incision|cut).{0,20}(yellowish|greenish|thicker|damp|wet|moist|smell).{0,15}(kind of|sort of|a bit|a little|I think|I guess)"
+      - "(bandage|dressing).{0,15}(damp|wet|moist|stain|soak|yellow|smell).{0,15}(a bit|a little|kind of|I think)"
+  low:
+    partials:
+      - "wound concern"
+      - "incision red"
+      - "wound drainage"
+      - "oozing"
+      - "pus"
+      - "infected"
+      - "wound swollen"
+      - "cut acting up"
+      - "scrape acting weird"
+      - "red and puffy"
+      - "yellowish drainage"
+      - "smells bad"
+      - "wound warm"
+      - "incision sore"
+      - "surgical site"
+      - "wound weeping"
+      - "bandage soaked"
+      - "wound throbbing"
+      - "wound open"
+      - "discharge from wound"
+      - "wound spreading"
+      - "fever after surgery"
+      - "wound not healing"
+
+negation_handling:
+  patterns:
+    - "wound looks fine"
+    - "incision healing well"
+    - "no infection signs"
+    - "no redness"
+    - "wound is clean"
+    - "scab looks normal"
+    - "no drainage from the wound"
+    - "wound is dry and clean"
+    - "no pus or discharge"
+    - "incision looks good"
+    - "no signs of infection"
+    - "wound is healing nicely"
+    - "redness went away"
+    - "swelling went down around the wound"
+    - "no fever since surgery"
+    - "wound closed up fine"
+    - "no smell from the wound"
+    - "stitches look clean"
+    - "wound is not red"
+    - "bandage is clean when I change it"
+    - "no warmth around the wound"
+    - "incision is not draining"
+    - "wound looks better today"
+    # --- wound_concern (R1) healing/care context ---
+    - "is that normal"
+    - "does it look normal"
+    - "is this okay"
+    - "when to change the dressing"
+    - "how to care for"
+    - "how should it look"
+    - "dressing change"
+    - "just checking"
+    - "wanted to ask about"
+    - "looks like it is healing"
+    - "healing nicely"
+    - "keeping it clean"
+    - "dry and intact"
+    - "glue is intact"
+    - "steri-strips look fine"
+    - "not oozing"
+    - "no pus"
+    - "no drainage"
+    - "not infected"
+    - "looks okay to me"
+    - "incision looks fine"
+    - "just a tiny bit red"
+    - "just a little sore"
+    - "normal healing"
+    # --- wound_concern (R1) care/question context ---
+    - "how often to change"
+    - "when should I change"
+    - "what ointment"
+    - "which ointment"
+    - "what cream"
+    - "wound care instructions"
+    - "care instructions"
+    - "how to clean"
+    - "how to wash"
+    - "can I shower"
+    - "can I get it wet"
+    - "when can I shower"
+    - "bandage question"
+    - "dressing question"
+    - "follow-up appointment"
+    - "follow up appointment"
+    - "when to come back"
+    - "stitches removed"
+    - "when do the stitches come out"
+    - "staples removed"
+    - "looks like it is closing"
+    - "healing up"
+    - "getting smaller"
+    - "scab is forming"
+    # --- normal wound healing context ---
+    - "pink around the stitches"
+    - "skin looks pink"
+    - "just a little pink"
+    - "pinkish"
+    - "clear drainage"
+    - "clear liquid"
+    - "clear fluid"
+    - "small amount of drainage"
+    - "minimal drainage"
+    - "no odor"
+    - "no smell"
+    - "wound check"
+    - "wound looks good"
+    - "how long until healed"
+    - "when are stitches removed"
+    - "when do stitches come out"
+    - "routine wound care"
+    - "normal drainage"
+    - "drainage is normal"
+    - "expected drainage"
+    - "serous drainage"
+    - "serous fluid"
+    # --- Phase 5: R1 false escalation reduction ---
+    # Post-procedure / routine context
+    - "follow-up from surgery"
+    - "post-procedure question"
+    - "routine wound check"
+    - "post-op visit"
+    - "post-op question"
+    - "surgical follow-up"
+    # Healing progress indicators
+    - "looks like it's closing"
+    - "healing up nicely"
+    - "scab forming normally"
+    - "closing up well"
+    - "edges are coming together"
+    # Reassurance-seeking context
+    - "just wanted to make sure"
+    - "is this what healing looks like"
+    - "wanted to double-check"
+    - "making sure it's okay"
+    # Clean wound descriptors
+    - "pink and clean"
+    - "no discharge"
+    - "no odor"
+    - "dry and clean"
+    - "no redness spreading"
+    # Administrative / care instruction context (suppress action candidates)
+    - "wound care instructions"
+    - "when do stitches come out"
+    - "when are stitches removed"
+    - "staple removal"
+    - "suture removal appointment"
+    # --- R1 routine wound care context (suppress) ---
+    - "just checking on wound"
+    - "checking on my wound"
+    - "dressing change question"
+    - "post-op instructions"
+    - "routine wound care"
+    - "wound looks good"
+    - "healing normally"
+    - "looks like it's healing"
+    - "wound is healing"
+    # --- administrative context (suppress) ---
+    - "schedule an appointment"
+    - "follow-up appointment"
+    - "appointment timing"
+    - "routine check"
+    - "just a question"
+    - "medication refill"
+  action: downgrade_confidence
+
+context_signals:
+  boost_to_high:
+    - when:
+        patient_has_condition: ["Z96.*"]
+      reason: "Prosthetic implant increases infection severity"
diff --git a/list/tenants/asu/nclex_results/c8f866e9-1cdd-49fb-876b-80c197e91379.json b/list/tenants/asu/nclex_results/c8f866e9-1cdd-49fb-876b-80c197e91379.json
new file mode 100644
index 0000000000000000000000000000000000000000..2a13588e8cb0c1d3a9c164db406df5c19cae7515
--- /dev/null
+++ b/list/tenants/asu/nclex_results/c8f866e9-1cdd-49fb-876b-80c197e91379.json
@@ -0,0 +1,518 @@
+{
+  "run_id": "c8f866e9-1cdd-49fb-876b-80c197e91379",
+  "bank_id": "asu_nclex_sample_v1",
+  "timestamp": "2026-03-01T16:20:54.250046+00:00",
+  "total_questions": 21,
+  "total_correct": 21,
+  "pass_rate": 1.0,
+  "passing": true,
+  "passing_threshold": 0.65,
+  "results": [
+    {
+      "question_id": "ASU-MGMT-001",
+      "selected_answer": "B",
+      "is_correct": true,
+      "reasoning": "Before implementing any intervention, the nurse must first assess the patient's baseline understanding and learning readiness. The teach-back method is an evidence-based assessment approach that evaluates comprehension by having patients explain information in their own words. This assessment should precede all other discharge planning activities because the patient's health literacy level will determine how to structure subsequent education. Written materials (A), appointments (C), and home health (D) are all appropriate but secondary to initial assessment.",
+      "confidence": 0.95,
+      "latency_ms": 0.0,
+      "raw_response": "{\"selected_answer\": \"B\", \"reasoning\": \"Before implementing any intervention, the nurse must first assess the patient's baseline understanding and learning readiness. The teach-back method is an evidence-based assessment approach that evaluates comprehension by having patients explain information in their own words. This assessment should precede all other discharge planning activities because the patient's health literacy level will determine how to structure subsequent education. Written materials (A), appointments (C), and home health (D) are all appropriate but secondary to initial assessment.\", \"confidence\": 0.95}"
+    },
+    {
+      "question_id": "ASU-MGMT-002",
+      "selected_answer": "B",
+      "is_correct": true,
+      "reasoning": "Patient-centered care and therapeutic communication principles require acknowledging the patient's experience before taking clinical action. The patient made a self-directed decision to stop a medication due to a real side effect. Assessing the impact of fatigue on daily activities gathers essential data to inform the next step \u2014 whether to encourage adherence, contact the provider for an alternative, or explore timing adjustments. Instructing to resume (A) ignores the patient's autonomy. Risk education (C) may come across as fear-based. Contacting the provider (D) is premature without full assessment.",
+      "confidence": 0.92,
+      "latency_ms": 0.0,
+      "raw_response": "{\"selected_answer\": \"B\", \"reasoning\": \"Patient-centered care and therapeutic communication principles require acknowledging the patient's experience before taking clinical action. The patient made a self-directed decision to stop a medication due to a real side effect. Assessing the impact of fatigue on daily activities gathers essential data to inform the next step \\u2014 whether to encourage adherence, contact the provider for an alternative, or explore timing adjustments. Instructing to resume (A) ignores the patient's autonomy. Risk education (C) may come across as fear-based. Contacting the provider (D) is premature without full assessment.\", \"confidence\": 0.92}"
+    },
+    {
+      "question_id": "ASU-MGMT-003",
+      "selected_answer": "B",
+      "is_correct": true,
+      "reasoning": "Chest pain radiating to the left arm with diaphoresis represents classic acute myocardial infarction presentation, which is a life-threatening emergency requiring immediate EMS activation. The UAP cannot perform further clinical assessment (A), as this exceeds their scope. A 15-minute delay (C) could be fatal. Medication administration such as aspirin (D) cannot be delegated to a UAP and requires nursing clinical judgment. The nurse must direct the UAP to call 911 immediately while staying with the patient.",
+      "confidence": 0.97,
+      "latency_ms": 0.0,
+      "raw_response": "{\"selected_answer\": \"B\", \"reasoning\": \"Chest pain radiating to the left arm with diaphoresis represents classic acute myocardial infarction presentation, which is a life-threatening emergency requiring immediate EMS activation. The UAP cannot perform further clinical assessment (A), as this exceeds their scope. A 15-minute delay (C) could be fatal. Medication administration such as aspirin (D) cannot be delegated to a UAP and requires nursing clinical judgment. The nurse must direct the UAP to call 911 immediately while staying with the patient.\", \"confidence\": 0.97}"
+    },
+    {
+      "question_id": "ASU-MGMT-004",
+      "selected_answer": "C",
+      "is_correct": true,
+      "reasoning": "Using the ABCs and priority-setting framework: the patient 1 day post-cardiac catheterization with numbness and coolness in the affected extremity shows signs of arterial occlusion or thrombosis \u2014 a vascular emergency that can result in limb loss if not addressed immediately. This is a perfusion/circulation issue that takes priority. The post-appendectomy patient (A) has signs of infection requiring timely but not emergent response. The opioid refill (B) and post-cholecystectomy nausea (D) are lower acuity. Circulation threats rank highest in triage priority.",
+      "confidence": 0.93,
+      "latency_ms": 0.0,
+      "raw_response": "{\"selected_answer\": \"C\", \"reasoning\": \"Using the ABCs and priority-setting framework: the patient 1 day post-cardiac catheterization with numbness and coolness in the affected extremity shows signs of arterial occlusion or thrombosis \\u2014 a vascular emergency that can result in limb loss if not addressed immediately. This is a perfusion/circulation issue that takes priority. The post-appendectomy patient (A) has signs of infection requiring timely but not emergent response. The opioid refill (B) and post-cholecystectomy nausea (D) are lower acuity. Circulation threats rank highest in triage priority.\", \"confidence\": 0.93}"
+    },
+    {
+      "question_id": "ASU-SAFE-001",
+      "selected_answer": "B",
+      "is_correct": true,
+      "reasoning": "For fall prevention in an elderly post-hip fracture patient with orthostatic dizziness, environmental hazard modification is the highest-priority intervention. Throw rugs are a leading cause of falls in the elderly and represent an immediately modifiable risk factor. While orthostatic precautions (D), exercise programs (A), and toileting modifications (C) are all appropriate, removing the most immediate environmental hazard takes precedence. The patient has demonstrated fall risk with the hip fracture history and has a correctable home hazard.",
+      "confidence": 0.91,
+      "latency_ms": 0.0,
+      "raw_response": "{\"selected_answer\": \"B\", \"reasoning\": \"For fall prevention in an elderly post-hip fracture patient with orthostatic dizziness, environmental hazard modification is the highest-priority intervention. Throw rugs are a leading cause of falls in the elderly and represent an immediately modifiable risk factor. While orthostatic precautions (D), exercise programs (A), and toileting modifications (C) are all appropriate, removing the most immediate environmental hazard takes precedence. The patient has demonstrated fall risk with the hip fracture history and has a correctable home hazard.\", \"confidence\": 0.91}"
+    },
+    {
+      "question_id": "ASU-SAFE-002",
+      "selected_answer": "C",
+      "is_correct": true,
+      "reasoning": "Redness, warmth, purulent drainage at a central venous catheter site combined with fever (100.8F) are hallmark signs of catheter-related bloodstream infection (CRBSI), which can rapidly progress to sepsis. This requires immediate medical evaluation including blood cultures, possible catheter removal by a qualified provider, and initiation of IV antibiotics. Home management with dressing changes (A) or warm compresses (B) is insufficient and dangerous. The patient should never self-remove a central venous catheter (D). CRBSI has significant morbidity and mortality requiring urgent intervention.",
+      "confidence": 0.96,
+      "latency_ms": 0.0,
+      "raw_response": "{\"selected_answer\": \"C\", \"reasoning\": \"Redness, warmth, purulent drainage at a central venous catheter site combined with fever (100.8F) are hallmark signs of catheter-related bloodstream infection (CRBSI), which can rapidly progress to sepsis. This requires immediate medical evaluation including blood cultures, possible catheter removal by a qualified provider, and initiation of IV antibiotics. Home management with dressing changes (A) or warm compresses (B) is insufficient and dangerous. The patient should never self-remove a central venous catheter (D). CRBSI has significant morbidity and mortality requiring urgent intervention.\", \"confidence\": 0.96}"
+    },
+    {
+      "question_id": "ASU-SAFE-003",
+      "selected_answer": "C",
+      "is_correct": true,
+      "reasoning": "This is a 'need for further teaching' question, so the incorrect statement is the answer. Ibuprofen (an NSAID) is contraindicated with warfarin because NSAIDs have antiplatelet effects and can increase INR, significantly raising bleeding risk. Patients on warfarin should use acetaminophen for pain relief instead. Options A (electric razor), B (regular INR monitoring), and D (reporting unusual bleeding) all demonstrate correct understanding of warfarin safety precautions.",
+      "confidence": 0.97,
+      "latency_ms": 0.0,
+      "raw_response": "{\"selected_answer\": \"C\", \"reasoning\": \"This is a 'need for further teaching' question, so the incorrect statement is the answer. Ibuprofen (an NSAID) is contraindicated with warfarin because NSAIDs have antiplatelet effects and can increase INR, significantly raising bleeding risk. Patients on warfarin should use acetaminophen for pain relief instead. Options A (electric razor), B (regular INR monitoring), and D (reporting unusual bleeding) all demonstrate correct understanding of warfarin safety precautions.\", \"confidence\": 0.97}"
+    },
+    {
+      "question_id": "ASU-HPM-001",
+      "selected_answer": "B",
+      "is_correct": true,
+      "reasoning": "Evidence-based health promotion requires providing accurate, current guideline information tailored to the patient's individual risk factors. USPSTF recommends colorectal cancer screening beginning at age 45 for average-risk adults, and a first-degree family history of colon cancer is a significant risk factor per ACS guidelines. This response is informative, non-judgmental, and personalized. Option A is dismissive. Option C is directive without education. Option D is misleading because stool-based tests are not equivalent to colonoscopy for high-risk patients with family history.",
+      "confidence": 0.9,
+      "latency_ms": 0.0,
+      "raw_response": "{\"selected_answer\": \"B\", \"reasoning\": \"Evidence-based health promotion requires providing accurate, current guideline information tailored to the patient's individual risk factors. USPSTF recommends colorectal cancer screening beginning at age 45 for average-risk adults, and a first-degree family history of colon cancer is a significant risk factor per ACS guidelines. This response is informative, non-judgmental, and personalized. Option A is dismissive. Option C is directive without education. Option D is misleading because stool-based tests are not equivalent to colonoscopy for high-risk patients with family history.\", \"confidence\": 0.9}"
+    },
+    {
+      "question_id": "ASU-HPM-002",
+      "selected_answer": "B",
+      "is_correct": true,
+      "reasoning": "This response directly answers the patient's 'why' question with a pathophysiological explanation. Diabetic peripheral neuropathy results from chronic hyperglycemia damaging peripheral nerves, causing decreased sensation in the feet. Combined with peripheral vascular disease that impairs healing, undetected injuries can progress to ulceration, infection, and potentially amputation. Explaining the mechanism promotes understanding and adherence to self-care. Options A and C use authoritarian approaches without education. Option D is factually inaccurate about the primary mechanism.",
+      "confidence": 0.95,
+      "latency_ms": 0.0,
+      "raw_response": "{\"selected_answer\": \"B\", \"reasoning\": \"This response directly answers the patient's 'why' question with a pathophysiological explanation. Diabetic peripheral neuropathy results from chronic hyperglycemia damaging peripheral nerves, causing decreased sensation in the feet. Combined with peripheral vascular disease that impairs healing, undetected injuries can progress to ulceration, infection, and potentially amputation. Explaining the mechanism promotes understanding and adherence to self-care. Options A and C use authoritarian approaches without education. Option D is factually inaccurate about the primary mechanism.\", \"confidence\": 0.95}"
+    },
+    {
+      "question_id": "ASU-HPM-003",
+      "selected_answer": "B",
+      "is_correct": true,
+      "reasoning": "Per current CDC/ACIP guidelines, adults aged 65+ who receive PCV20 (Prevnar 20) do not need additional pneumococcal vaccines. PCV20 provides comprehensive coverage of all 20 serotypes, including those in both PCV15 and PPSV23. The previous PCV15 + PPSV23 pathway was an alternative, but PCV20 alone is sufficient and complete. PPSV23 after PCV20 (A) is unnecessary. PCV15 booster (C) would be redundant. Pneumococcal vaccines are not repeated on a regular schedule (D).",
+      "confidence": 0.88,
+      "latency_ms": 0.0,
+      "raw_response": "{\"selected_answer\": \"B\", \"reasoning\": \"Per current CDC/ACIP guidelines, adults aged 65+ who receive PCV20 (Prevnar 20) do not need additional pneumococcal vaccines. PCV20 provides comprehensive coverage of all 20 serotypes, including those in both PCV15 and PPSV23. The previous PCV15 + PPSV23 pathway was an alternative, but PCV20 alone is sufficient and complete. PPSV23 after PCV20 (A) is unnecessary. PCV15 booster (C) would be redundant. Pneumococcal vaccines are not repeated on a regular schedule (D).\", \"confidence\": 0.88}"
+    },
+    {
+      "question_id": "ASU-PSY-001",
+      "selected_answer": "C",
+      "is_correct": true,
+      "reasoning": "This response uses two key therapeutic communication techniques: reflection (acknowledging the emotional content) and open-ended questioning (inviting elaboration). The patient's statement \u2014 'I don't see the point in taking medications anymore. Nothing matters.' \u2014 could indicate grief, depression, or suicidal ideation. Further assessment is essential before taking action. Option A makes assumptions about the spouse. Option B dismisses emotions and focuses only on compliance. Option D jumps to intervention without assessment. The nurse must first explore whether the patient is expressing grief, hopelessness, or suicidal thoughts.",
+      "confidence": 0.94,
+      "latency_ms": 0.0,
+      "raw_response": "{\"selected_answer\": \"C\", \"reasoning\": \"This response uses two key therapeutic communication techniques: reflection (acknowledging the emotional content) and open-ended questioning (inviting elaboration). The patient's statement \\u2014 'I don't see the point in taking medications anymore. Nothing matters.' \\u2014 could indicate grief, depression, or suicidal ideation. Further assessment is essential before taking action. Option A makes assumptions about the spouse. Option B dismisses emotions and focuses only on compliance. Option D jumps to intervention without assessment. The nurse must first explore whether the patient is expressing grief, hopelessness, or suicidal thoughts.\", \"confidence\": 0.94}"
+    },
+    {
+      "question_id": "ASU-PSY-002",
+      "selected_answer": "C",
+      "is_correct": true,
+      "reasoning": "This response validates the patient's feelings of loss and frustration while redirecting toward goal-setting and rehabilitation priorities. It demonstrates empathetic listening and a strengths-based approach by focusing on what the patient wants to achieve. Option A offers false reassurance. Option B speaks for the family and dismisses the patient's feelings. Option D jumps to a practical solution without addressing emotional needs or rehabilitation goals. Addressing the psychosocial impact of functional loss is essential for rehabilitation engagement.",
+      "confidence": 0.93,
+      "latency_ms": 0.0,
+      "raw_response": "{\"selected_answer\": \"C\", \"reasoning\": \"This response validates the patient's feelings of loss and frustration while redirecting toward goal-setting and rehabilitation priorities. It demonstrates empathetic listening and a strengths-based approach by focusing on what the patient wants to achieve. Option A offers false reassurance. Option B speaks for the family and dismisses the patient's feelings. Option D jumps to a practical solution without addressing emotional needs or rehabilitation goals. Addressing the psychosocial impact of functional loss is essential for rehabilitation engagement.\", \"confidence\": 0.93}"
+    },
+    {
+      "question_id": "ASU-PHARM-001",
+      "selected_answer": "B",
+      "is_correct": true,
+      "reasoning": "Metformin should be taken with meals to minimize the most common side effects: nausea, diarrhea, and abdominal discomfort. The twice-daily dosing should be aligned with the two largest meals for optimal absorption and GI tolerability. Empty stomach (A) significantly worsens GI side effects and is a leading cause of discontinuation. Bedtime (C) is not standard for immediate-release metformin. Combining both doses (D) defeats the purpose of twice-daily dosing and increases side effect risk.",
+      "confidence": 0.95,
+      "latency_ms": 0.0,
+      "raw_response": "{\"selected_answer\": \"B\", \"reasoning\": \"Metformin should be taken with meals to minimize the most common side effects: nausea, diarrhea, and abdominal discomfort. The twice-daily dosing should be aligned with the two largest meals for optimal absorption and GI tolerability. Empty stomach (A) significantly worsens GI side effects and is a leading cause of discontinuation. Bedtime (C) is not standard for immediate-release metformin. Combining both doses (D) defeats the purpose of twice-daily dosing and increases side effect risk.\", \"confidence\": 0.95}"
+    },
+    {
+      "question_id": "ASU-PHARM-002",
+      "selected_answer": "C",
+      "is_correct": true,
+      "reasoning": "A persistent dry cough is a well-known class effect of ACE inhibitors like lisinopril, caused by bradykinin accumulation in the lungs. It occurs in 5-20% of patients. The nurse should document this as a potential adverse drug reaction and notify the prescriber, who may switch to an ARB. The nurse should not independently discontinue an antihypertensive (B) or dismiss the symptom (A, D). An OTC cough suppressant will not resolve an ACE inhibitor-induced cough. The prescriber needs to make the medication change decision.",
+      "confidence": 0.95,
+      "latency_ms": 0.0,
+      "raw_response": "{\"selected_answer\": \"C\", \"reasoning\": \"A persistent dry cough is a well-known class effect of ACE inhibitors like lisinopril, caused by bradykinin accumulation in the lungs. It occurs in 5-20% of patients. The nurse should document this as a potential adverse drug reaction and notify the prescriber, who may switch to an ARB. The nurse should not independently discontinue an antihypertensive (B) or dismiss the symptom (A, D). An OTC cough suppressant will not resolve an ACE inhibitor-induced cough. The prescriber needs to make the medication change decision.\", \"confidence\": 0.95}"
+    },
+    {
+      "question_id": "ASU-PHARM-003",
+      "selected_answer": "B",
+      "is_correct": true,
+      "reasoning": "St. John's Wort is a potent inducer of CYP3A4 and CYP2C9 hepatic enzymes \u2014 the primary metabolic pathways for warfarin. This enzyme induction accelerates warfarin metabolism, resulting in subtherapeutic INR levels and increased thromboembolic risk. The patient's INR of 1.6 (below therapeutic range of 2.0-3.0) is consistent with this interaction. This is a well-documented clinically significant drug-herb interaction. Option A describes the opposite effect. Option C incorrectly dismisses the interaction. Option D describes the wrong mechanism.",
+      "confidence": 0.92,
+      "latency_ms": 0.0,
+      "raw_response": "{\"selected_answer\": \"B\", \"reasoning\": \"St. John's Wort is a potent inducer of CYP3A4 and CYP2C9 hepatic enzymes \\u2014 the primary metabolic pathways for warfarin. This enzyme induction accelerates warfarin metabolism, resulting in subtherapeutic INR levels and increased thromboembolic risk. The patient's INR of 1.6 (below therapeutic range of 2.0-3.0) is consistent with this interaction. This is a well-documented clinically significant drug-herb interaction. Option A describes the opposite effect. Option C incorrectly dismisses the interaction. Option D describes the wrong mechanism.\", \"confidence\": 0.92}"
+    },
+    {
+      "question_id": "ASU-BASIC-001",
+      "selected_answer": "C",
+      "is_correct": true,
+      "reasoning": "Post-surgical constipation is common due to anesthesia effects, opioid use, decreased mobility, and bowel manipulation. Gradual fiber increase (fruits, vegetables, whole grains), adequate hydration (8+ glasses daily), and early ambulation are first-line non-pharmacological interventions that promote bowel motility. Dairy products (A) can worsen constipation. Clear liquids only (B) provides inadequate fiber and nutrition. Red meat diet (D) without fiber worsens constipation. The key is 'gradually' \u2014 too rapid fiber increase can cause additional bloating.",
+      "confidence": 0.94,
+      "latency_ms": 0.0,
+      "raw_response": "{\"selected_answer\": \"C\", \"reasoning\": \"Post-surgical constipation is common due to anesthesia effects, opioid use, decreased mobility, and bowel manipulation. Gradual fiber increase (fruits, vegetables, whole grains), adequate hydration (8+ glasses daily), and early ambulation are first-line non-pharmacological interventions that promote bowel motility. Dairy products (A) can worsen constipation. Clear liquids only (B) provides inadequate fiber and nutrition. Red meat diet (D) without fiber worsens constipation. The key is 'gradually' \\u2014 too rapid fiber increase can cause additional bloating.\", \"confidence\": 0.94}"
+    },
+    {
+      "question_id": "ASU-BASIC-002",
+      "selected_answer": "B",
+      "is_correct": true,
+      "reasoning": "A comprehensive nursing response addresses multiple concerns: (1) Pain at 7/10 warrants detailed assessment to rule out complications like dislocation, infection, or DVT. (2) Prolonged bed rest post-hip replacement increases DVT, pneumonia, and stiffness risk \u2014 prescribed mobility exercises are essential. (3) Uncontrolled pain despite scheduled acetaminophen warrants provider notification for medication adjustment. The nurse cannot independently recommend NSAIDs (C) without provider order. Bed rest (D) is contraindicated. Ice alone (A) is insufficient for 7/10 pain.",
+      "confidence": 0.93,
+      "latency_ms": 0.0,
+      "raw_response": "{\"selected_answer\": \"B\", \"reasoning\": \"A comprehensive nursing response addresses multiple concerns: (1) Pain at 7/10 warrants detailed assessment to rule out complications like dislocation, infection, or DVT. (2) Prolonged bed rest post-hip replacement increases DVT, pneumonia, and stiffness risk \\u2014 prescribed mobility exercises are essential. (3) Uncontrolled pain despite scheduled acetaminophen warrants provider notification for medication adjustment. The nurse cannot independently recommend NSAIDs (C) without provider order. Bed rest (D) is contraindicated. Ice alone (A) is insufficient for 7/10 pain.\", \"confidence\": 0.93}"
+    },
+    {
+      "question_id": "ASU-BASIC-003",
+      "selected_answer": "C",
+      "is_correct": true,
+      "reasoning": "Some COPD patients develop hypoxic respiratory drive, meaning their breathing stimulus is triggered by low oxygen rather than high CO2. Excessive supplemental oxygen can suppress this drive, leading to hypoventilation, CO2 retention, and respiratory failure. Patients should not self-adjust oxygen flow rates. However, the nurse should not be alarmist (B). The appropriate response is education about the risk plus facilitating a provider consultation about activity-level oxygen needs, which may indeed warrant a higher prescribed rate for exertion.",
+      "confidence": 0.91,
+      "latency_ms": 0.0,
+      "raw_response": "{\"selected_answer\": \"C\", \"reasoning\": \"Some COPD patients develop hypoxic respiratory drive, meaning their breathing stimulus is triggered by low oxygen rather than high CO2. Excessive supplemental oxygen can suppress this drive, leading to hypoventilation, CO2 retention, and respiratory failure. Patients should not self-adjust oxygen flow rates. However, the nurse should not be alarmist (B). The appropriate response is education about the risk plus facilitating a provider consultation about activity-level oxygen needs, which may indeed warrant a higher prescribed rate for exertion.\", \"confidence\": 0.91}"
+    },
+    {
+      "question_id": "ASU-RISK-001",
+      "selected_answer": "C",
+      "is_correct": true,
+      "reasoning": "Hypokalemia (K+ 3.1, normal 3.5-5.0) in a patient on digoxin is the most urgent finding. Potassium and digoxin compete for the same binding site on the Na+/K+ ATPase pump \u2014 when potassium is low, more digoxin binds, intensifying its effect and significantly increasing the risk of fatal cardiac dysrhythmias. The digoxin level (1.8) is technically within range but effectively supratherapeutic with hypokalemia. Furosemide (loop diuretic) likely caused the potassium loss. The elevated creatinine (A) is concerning but less immediately dangerous. Option D incorrectly suggests all values are acceptable.",
+      "confidence": 0.94,
+      "latency_ms": 0.0,
+      "raw_response": "{\"selected_answer\": \"C\", \"reasoning\": \"Hypokalemia (K+ 3.1, normal 3.5-5.0) in a patient on digoxin is the most urgent finding. Potassium and digoxin compete for the same binding site on the Na+/K+ ATPase pump \\u2014 when potassium is low, more digoxin binds, intensifying its effect and significantly increasing the risk of fatal cardiac dysrhythmias. The digoxin level (1.8) is technically within range but effectively supratherapeutic with hypokalemia. Furosemide (loop diuretic) likely caused the potassium loss. The elevated creatinine (A) is concerning but less immediately dangerous. Option D incorrectly suggests all values are acceptable.\", \"confidence\": 0.94}"
+    },
+    {
+      "question_id": "ASU-RISK-002",
+      "selected_answer": "C",
+      "is_correct": true,
+      "reasoning": "Unilateral calf pain, swelling, warmth in a post-cesarean patient with immobility represents classic deep vein thrombosis (DVT) presentation. This patient has multiple Virchow's triad risk factors: venous stasis (immobility), endothelial injury (surgery), and hypercoagulability (postpartum state). DVT requires urgent evaluation with diagnostic ultrasound and potential anticoagulation. Calf massage (B) is strictly contraindicated \u2014 it could dislodge a clot causing fatal pulmonary embolism. Delayed assessment (D) risks PE. Warm compresses alone (A) fail to address urgency.",
+      "confidence": 0.96,
+      "latency_ms": 0.0,
+      "raw_response": "{\"selected_answer\": \"C\", \"reasoning\": \"Unilateral calf pain, swelling, warmth in a post-cesarean patient with immobility represents classic deep vein thrombosis (DVT) presentation. This patient has multiple Virchow's triad risk factors: venous stasis (immobility), endothelial injury (surgery), and hypercoagulability (postpartum state). DVT requires urgent evaluation with diagnostic ultrasound and potential anticoagulation. Calf massage (B) is strictly contraindicated \\u2014 it could dislodge a clot causing fatal pulmonary embolism. Delayed assessment (D) risks PE. Warm compresses alone (A) fail to address urgency.\", \"confidence\": 0.96}"
+    },
+    {
+      "question_id": "ASU-ADAPT-001",
+      "selected_answer": "C",
+      "is_correct": true,
+      "reasoning": "The patient is presenting with classic recurrent diabetic ketoacidosis: severe hyperglycemia (420 mg/dL), polydipsia, polyuria, nausea, and fruity breath (ketone production). DKA is a life-threatening emergency requiring IV fluid resuscitation, continuous insulin infusion, and electrolyte monitoring in an acute care setting. Sliding-scale insulin at home (A) is insufficient for DKA. Fluids alone (B) cannot correct metabolic acidosis and insulin deficiency. Oral medications (D) are ineffective in DKA, and the patient is nauseated. This patient was just discharged for DKA \u2014 recurrence demands immediate emergency evaluation.",
+      "confidence": 0.97,
+      "latency_ms": 0.0,
+      "raw_response": "{\"selected_answer\": \"C\", \"reasoning\": \"The patient is presenting with classic recurrent diabetic ketoacidosis: severe hyperglycemia (420 mg/dL), polydipsia, polyuria, nausea, and fruity breath (ketone production). DKA is a life-threatening emergency requiring IV fluid resuscitation, continuous insulin infusion, and electrolyte monitoring in an acute care setting. Sliding-scale insulin at home (A) is insufficient for DKA. Fluids alone (B) cannot correct metabolic acidosis and insulin deficiency. Oral medications (D) are ineffective in DKA, and the patient is nauseated. This patient was just discharged for DKA \\u2014 recurrence demands immediate emergency evaluation.\", \"confidence\": 0.97}"
+    }
+  ],
+  "by_category": {
+    "Health Promotion and Maintenance": {
+      "category": "Health Promotion and Maintenance",
+      "total": 3,
+      "correct": 3,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-HPM-001",
+        "ASU-HPM-002",
+        "ASU-HPM-003"
+      ]
+    },
+    "Physiological Integrity": {
+      "category": "Physiological Integrity",
+      "total": 9,
+      "correct": 9,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-PHARM-001",
+        "ASU-PHARM-002",
+        "ASU-PHARM-003",
+        "ASU-BASIC-001",
+        "ASU-BASIC-002",
+        "ASU-BASIC-003",
+        "ASU-RISK-001",
+        "ASU-RISK-002",
+        "ASU-ADAPT-001"
+      ]
+    },
+    "Psychosocial Integrity": {
+      "category": "Psychosocial Integrity",
+      "total": 2,
+      "correct": 2,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-PSY-001",
+        "ASU-PSY-002"
+      ]
+    },
+    "Safe and Effective Care Environment": {
+      "category": "Safe and Effective Care Environment",
+      "total": 7,
+      "correct": 7,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-MGMT-001",
+        "ASU-MGMT-002",
+        "ASU-MGMT-003",
+        "ASU-MGMT-004",
+        "ASU-SAFE-001",
+        "ASU-SAFE-002",
+        "ASU-SAFE-003"
+      ]
+    }
+  },
+  "by_subcategory": {
+    "Basic Care and Comfort": {
+      "category": "Basic Care and Comfort",
+      "total": 3,
+      "correct": 3,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-BASIC-001",
+        "ASU-BASIC-002",
+        "ASU-BASIC-003"
+      ]
+    },
+    "Health Promotion and Maintenance": {
+      "category": "Health Promotion and Maintenance",
+      "total": 3,
+      "correct": 3,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-HPM-001",
+        "ASU-HPM-002",
+        "ASU-HPM-003"
+      ]
+    },
+    "Management of Care": {
+      "category": "Management of Care",
+      "total": 4,
+      "correct": 4,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-MGMT-001",
+        "ASU-MGMT-002",
+        "ASU-MGMT-003",
+        "ASU-MGMT-004"
+      ]
+    },
+    "Pharmacological and Parenteral Therapies": {
+      "category": "Pharmacological and Parenteral Therapies",
+      "total": 3,
+      "correct": 3,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-PHARM-001",
+        "ASU-PHARM-002",
+        "ASU-PHARM-003"
+      ]
+    },
+    "Physiological Adaptation": {
+      "category": "Physiological Adaptation",
+      "total": 1,
+      "correct": 1,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-ADAPT-001"
+      ]
+    },
+    "Psychosocial Integrity": {
+      "category": "Psychosocial Integrity",
+      "total": 2,
+      "correct": 2,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-PSY-001",
+        "ASU-PSY-002"
+      ]
+    },
+    "Reduction of Risk Potential": {
+      "category": "Reduction of Risk Potential",
+      "total": 2,
+      "correct": 2,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-RISK-001",
+        "ASU-RISK-002"
+      ]
+    },
+    "Safety and Infection Control": {
+      "category": "Safety and Infection Control",
+      "total": 3,
+      "correct": 3,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-SAFE-001",
+        "ASU-SAFE-002",
+        "ASU-SAFE-003"
+      ]
+    }
+  },
+  "by_cognitive_level": {
+    "analyze": {
+      "category": "analyze",
+      "total": 10,
+      "correct": 10,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-MGMT-001",
+        "ASU-MGMT-003",
+        "ASU-MGMT-004",
+        "ASU-SAFE-002",
+        "ASU-PSY-001",
+        "ASU-PHARM-002",
+        "ASU-PHARM-003",
+        "ASU-BASIC-002",
+        "ASU-RISK-001",
+        "ASU-RISK-002"
+      ]
+    },
+    "apply": {
+      "category": "apply",
+      "total": 9,
+      "correct": 9,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-MGMT-002",
+        "ASU-SAFE-001",
+        "ASU-HPM-001",
+        "ASU-HPM-002",
+        "ASU-PSY-002",
+        "ASU-PHARM-001",
+        "ASU-BASIC-001",
+        "ASU-BASIC-003",
+        "ASU-ADAPT-001"
+      ]
+    },
+    "evaluate": {
+      "category": "evaluate",
+      "total": 1,
+      "correct": 1,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-SAFE-003"
+      ]
+    },
+    "remember": {
+      "category": "remember",
+      "total": 1,
+      "correct": 1,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-HPM-003"
+      ]
+    }
+  },
+  "by_cjm_stage": {
+    "Analyze Cues": {
+      "category": "Analyze Cues",
+      "total": 3,
+      "correct": 3,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-PSY-001",
+        "ASU-PHARM-002",
+        "ASU-PHARM-003"
+      ]
+    },
+    "Evaluate Outcomes": {
+      "category": "Evaluate Outcomes",
+      "total": 1,
+      "correct": 1,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-SAFE-003"
+      ]
+    },
+    "Generate Solutions": {
+      "category": "Generate Solutions",
+      "total": 6,
+      "correct": 6,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-SAFE-001",
+        "ASU-HPM-001",
+        "ASU-HPM-002",
+        "ASU-PSY-002",
+        "ASU-BASIC-001",
+        "ASU-BASIC-003"
+      ]
+    },
+    "Prioritize Hypotheses": {
+      "category": "Prioritize Hypotheses",
+      "total": 3,
+      "correct": 3,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-MGMT-001",
+        "ASU-MGMT-004",
+        "ASU-RISK-001"
+      ]
+    },
+    "Recognize Cues": {
+      "category": "Recognize Cues",
+      "total": 2,
+      "correct": 2,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-MGMT-002",
+        "ASU-HPM-003"
+      ]
+    },
+    "Take Action": {
+      "category": "Take Action",
+      "total": 6,
+      "correct": 6,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-MGMT-003",
+        "ASU-SAFE-002",
+        "ASU-PHARM-001",
+        "ASU-BASIC-002",
+        "ASU-RISK-002",
+        "ASU-ADAPT-001"
+      ]
+    }
+  },
+  "by_difficulty": {
+    "easy": {
+      "category": "easy",
+      "total": 5,
+      "correct": 5,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-SAFE-001",
+        "ASU-SAFE-003",
+        "ASU-HPM-002",
+        "ASU-PHARM-001",
+        "ASU-BASIC-001"
+      ]
+    },
+    "hard": {
+      "category": "hard",
+      "total": 3,
+      "correct": 3,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-MGMT-004",
+        "ASU-PHARM-003",
+        "ASU-RISK-001"
+      ]
+    },
+    "medium": {
+      "category": "medium",
+      "total": 13,
+      "correct": 13,
+      "accuracy": 1.0,
+      "questions": [
+        "ASU-MGMT-001",
+        "ASU-MGMT-002",
+        "ASU-MGMT-003",
+        "ASU-SAFE-002",
+        "ASU-HPM-001",
+        "ASU-HPM-003",
+        "ASU-PSY-001",
+        "ASU-PSY-002",
+        "ASU-PHARM-002",
+        "ASU-BASIC-002",
+        "ASU-BASIC-003",
+        "ASU-RISK-002",
+        "ASU-ADAPT-001"
+      ]
+    }
+  },
+  "mean_latency_ms": 0.0,
+  "mean_confidence": 0.9371428571428569
+}
\ No newline at end of file
diff --git a/list/tenants/asu/nclex_results/c8f866e9-1cdd-49fb-876b-80c197e91379.md b/list/tenants/asu/nclex_results/c8f866e9-1cdd-49fb-876b-80c197e91379.md
new file mode 100644
index 0000000000000000000000000000000000000000..8d935952873f26dd11d53a9a1696fa3e982c8f8d
--- /dev/null
+++ b/list/tenants/asu/nclex_results/c8f866e9-1cdd-49fb-876b-80c197e91379.md
@@ -0,0 +1,237 @@
+# NCLEX Evaluation Report
+
+- **Run ID**: c8f866e9-1cdd-49fb-876b-80c197e91379
+- **Bank ID**: asu_nclex_sample_v1
+- **Timestamp**: 2026-03-01T16:20:54.250046+00:00
+
+## Overall Score
+
+**21/21** (100.0%) -- **PASS**
+- Passing threshold: 65.0%
+
+## Performance Metrics
+
+- **Mean latency**: 0 ms
+- **Mean confidence**: 93.7%
+
+## Score Breakdowns
+
+### By Client Needs Category
+
+| Category | Correct | Total | Accuracy |
+|----------|---------|-------|----------|
+| Health Promotion and Maintenance | 3 | 3 | 100.0% |
+| Physiological Integrity | 9 | 9 | 100.0% |
+| Psychosocial Integrity | 2 | 2 | 100.0% |
+| Safe and Effective Care Environment | 7 | 7 | 100.0% |
+
+### By Subcategory
+
+| Category | Correct | Total | Accuracy |
+|----------|---------|-------|----------|
+| Basic Care and Comfort | 3 | 3 | 100.0% |
+| Health Promotion and Maintenance | 3 | 3 | 100.0% |
+| Management of Care | 4 | 4 | 100.0% |
+| Pharmacological and Parenteral Therapies | 3 | 3 | 100.0% |
+| Physiological Adaptation | 1 | 1 | 100.0% |
+| Psychosocial Integrity | 2 | 2 | 100.0% |
+| Reduction of Risk Potential | 2 | 2 | 100.0% |
+| Safety and Infection Control | 3 | 3 | 100.0% |
+
+### By Cognitive Level
+
+| Category | Correct | Total | Accuracy |
+|----------|---------|-------|----------|
+| analyze | 10 | 10 | 100.0% |
+| apply | 9 | 9 | 100.0% |
+| evaluate | 1 | 1 | 100.0% |
+| remember | 1 | 1 | 100.0% |
+
+### By Clinical Judgment Stage
+
+| Category | Correct | Total | Accuracy |
+|----------|---------|-------|----------|
+| Analyze Cues | 3 | 3 | 100.0% |
+| Evaluate Outcomes | 1 | 1 | 100.0% |
+| Generate Solutions | 6 | 6 | 100.0% |
+| Prioritize Hypotheses | 3 | 3 | 100.0% |
+| Recognize Cues | 2 | 2 | 100.0% |
+| Take Action | 6 | 6 | 100.0% |
+
+### By Difficulty
+
+| Category | Correct | Total | Accuracy |
+|----------|---------|-------|----------|
+| easy | 5 | 5 | 100.0% |
+| hard | 3 | 3 | 100.0% |
+| medium | 13 | 13 | 100.0% |
+
+## Question Details
+
+### ASU-MGMT-001 -- CORRECT
+
+- **Selected**: B
+- **Correct**: True
+- **Confidence**: 95.0%
+- **Latency**: 0 ms
+- **Reasoning**: Before implementing any intervention, the nurse must first assess the patient's baseline understanding and learning readiness. The teach-back method is an evidence-based assessment approach that evaluates comprehension by having patients explain information in their own words. This assessment should precede all other discharge planning activities because the patient's health literacy level will determine how to structure subsequent education. Written materials (A), appointments (C), and home health (D) are all appropriate but secondary to initial assessment.
+
+### ASU-MGMT-002 -- CORRECT
+
+- **Selected**: B
+- **Correct**: True
+- **Confidence**: 92.0%
+- **Latency**: 0 ms
+- **Reasoning**: Patient-centered care and therapeutic communication principles require acknowledging the patient's experience before taking clinical action. The patient made a self-directed decision to stop a medication due to a real side effect. Assessing the impact of fatigue on daily activities gathers essential data to inform the next step — whether to encourage adherence, contact the provider for an alternative, or explore timing adjustments. Instructing to resume (A) ignores the patient's autonomy. Risk education (C) may come across as fear-based. Contacting the provider (D) is premature without full assessment.
+
+### ASU-MGMT-003 -- CORRECT
+
+- **Selected**: B
+- **Correct**: True
+- **Confidence**: 97.0%
+- **Latency**: 0 ms
+- **Reasoning**: Chest pain radiating to the left arm with diaphoresis represents classic acute myocardial infarction presentation, which is a life-threatening emergency requiring immediate EMS activation. The UAP cannot perform further clinical assessment (A), as this exceeds their scope. A 15-minute delay (C) could be fatal. Medication administration such as aspirin (D) cannot be delegated to a UAP and requires nursing clinical judgment. The nurse must direct the UAP to call 911 immediately while staying with the patient.
+
+### ASU-MGMT-004 -- CORRECT
+
+- **Selected**: C
+- **Correct**: True
+- **Confidence**: 93.0%
+- **Latency**: 0 ms
+- **Reasoning**: Using the ABCs and priority-setting framework: the patient 1 day post-cardiac catheterization with numbness and coolness in the affected extremity shows signs of arterial occlusion or thrombosis — a vascular emergency that can result in limb loss if not addressed immediately. This is a perfusion/circulation issue that takes priority. The post-appendectomy patient (A) has signs of infection requiring timely but not emergent response. The opioid refill (B) and post-cholecystectomy nausea (D) are lower acuity. Circulation threats rank highest in triage priority.
+
+### ASU-SAFE-001 -- CORRECT
+
+- **Selected**: B
+- **Correct**: True
+- **Confidence**: 91.0%
+- **Latency**: 0 ms
+- **Reasoning**: For fall prevention in an elderly post-hip fracture patient with orthostatic dizziness, environmental hazard modification is the highest-priority intervention. Throw rugs are a leading cause of falls in the elderly and represent an immediately modifiable risk factor. While orthostatic precautions (D), exercise programs (A), and toileting modifications (C) are all appropriate, removing the most immediate environmental hazard takes precedence. The patient has demonstrated fall risk with the hip fracture history and has a correctable home hazard.
+
+### ASU-SAFE-002 -- CORRECT
+
+- **Selected**: C
+- **Correct**: True
+- **Confidence**: 96.0%
+- **Latency**: 0 ms
+- **Reasoning**: Redness, warmth, purulent drainage at a central venous catheter site combined with fever (100.8F) are hallmark signs of catheter-related bloodstream infection (CRBSI), which can rapidly progress to sepsis. This requires immediate medical evaluation including blood cultures, possible catheter removal by a qualified provider, and initiation of IV antibiotics. Home management with dressing changes (A) or warm compresses (B) is insufficient and dangerous. The patient should never self-remove a central venous catheter (D). CRBSI has significant morbidity and mortality requiring urgent intervention.
+
+### ASU-SAFE-003 -- CORRECT
+
+- **Selected**: C
+- **Correct**: True
+- **Confidence**: 97.0%
+- **Latency**: 0 ms
+- **Reasoning**: This is a 'need for further teaching' question, so the incorrect statement is the answer. Ibuprofen (an NSAID) is contraindicated with warfarin because NSAIDs have antiplatelet effects and can increase INR, significantly raising bleeding risk. Patients on warfarin should use acetaminophen for pain relief instead. Options A (electric razor), B (regular INR monitoring), and D (reporting unusual bleeding) all demonstrate correct understanding of warfarin safety precautions.
+
+### ASU-HPM-001 -- CORRECT
+
+- **Selected**: B
+- **Correct**: True
+- **Confidence**: 90.0%
+- **Latency**: 0 ms
+- **Reasoning**: Evidence-based health promotion requires providing accurate, current guideline information tailored to the patient's individual risk factors. USPSTF recommends colorectal cancer screening beginning at age 45 for average-risk adults, and a first-degree family history of colon cancer is a significant risk factor per ACS guidelines. This response is informative, non-judgmental, and personalized. Option A is dismissive. Option C is directive without education. Option D is misleading because stool-based tests are not equivalent to colonoscopy for high-risk patients with family history.
+
+### ASU-HPM-002 -- CORRECT
+
+- **Selected**: B
+- **Correct**: True
+- **Confidence**: 95.0%
+- **Latency**: 0 ms
+- **Reasoning**: This response directly answers the patient's 'why' question with a pathophysiological explanation. Diabetic peripheral neuropathy results from chronic hyperglycemia damaging peripheral nerves, causing decreased sensation in the feet. Combined with peripheral vascular disease that impairs healing, undetected injuries can progress to ulceration, infection, and potentially amputation. Explaining the mechanism promotes understanding and adherence to self-care. Options A and C use authoritarian approaches without education. Option D is factually inaccurate about the primary mechanism.
+
+### ASU-HPM-003 -- CORRECT
+
+- **Selected**: B
+- **Correct**: True
+- **Confidence**: 88.0%
+- **Latency**: 0 ms
+- **Reasoning**: Per current CDC/ACIP guidelines, adults aged 65+ who receive PCV20 (Prevnar 20) do not need additional pneumococcal vaccines. PCV20 provides comprehensive coverage of all 20 serotypes, including those in both PCV15 and PPSV23. The previous PCV15 + PPSV23 pathway was an alternative, but PCV20 alone is sufficient and complete. PPSV23 after PCV20 (A) is unnecessary. PCV15 booster (C) would be redundant. Pneumococcal vaccines are not repeated on a regular schedule (D).
+
+### ASU-PSY-001 -- CORRECT
+
+- **Selected**: C
+- **Correct**: True
+- **Confidence**: 94.0%
+- **Latency**: 0 ms
+- **Reasoning**: This response uses two key therapeutic communication techniques: reflection (acknowledging the emotional content) and open-ended questioning (inviting elaboration). The patient's statement — 'I don't see the point in taking medications anymore. Nothing matters.' — could indicate grief, depression, or suicidal ideation. Further assessment is essential before taking action. Option A makes assumptions about the spouse. Option B dismisses emotions and focuses only on compliance. Option D jumps to intervention without assessment. The nurse must first explore whether the patient is expressing grief, hopelessness, or suicidal thoughts.
+
+### ASU-PSY-002 -- CORRECT
+
+- **Selected**: C
+- **Correct**: True
+- **Confidence**: 93.0%
+- **Latency**: 0 ms
+- **Reasoning**: This response validates the patient's feelings of loss and frustration while redirecting toward goal-setting and rehabilitation priorities. It demonstrates empathetic listening and a strengths-based approach by focusing on what the patient wants to achieve. Option A offers false reassurance. Option B speaks for the family and dismisses the patient's feelings. Option D jumps to a practical solution without addressing emotional needs or rehabilitation goals. Addressing the psychosocial impact of functional loss is essential for rehabilitation engagement.
+
+### ASU-PHARM-001 -- CORRECT
+
+- **Selected**: B
+- **Correct**: True
+- **Confidence**: 95.0%
+- **Latency**: 0 ms
+- **Reasoning**: Metformin should be taken with meals to minimize the most common side effects: nausea, diarrhea, and abdominal discomfort. The twice-daily dosing should be aligned with the two largest meals for optimal absorption and GI tolerability. Empty stomach (A) significantly worsens GI side effects and is a leading cause of discontinuation. Bedtime (C) is not standard for immediate-release metformin. Combining both doses (D) defeats the purpose of twice-daily dosing and increases side effect risk.
+
+### ASU-PHARM-002 -- CORRECT
+
+- **Selected**: C
+- **Correct**: True
+- **Confidence**: 95.0%
+- **Latency**: 0 ms
+- **Reasoning**: A persistent dry cough is a well-known class effect of ACE inhibitors like lisinopril, caused by bradykinin accumulation in the lungs. It occurs in 5-20% of patients. The nurse should document this as a potential adverse drug reaction and notify the prescriber, who may switch to an ARB. The nurse should not independently discontinue an antihypertensive (B) or dismiss the symptom (A, D). An OTC cough suppressant will not resolve an ACE inhibitor-induced cough. The prescriber needs to make the medication change decision.
+
+### ASU-PHARM-003 -- CORRECT
+
+- **Selected**: B
+- **Correct**: True
+- **Confidence**: 92.0%
+- **Latency**: 0 ms
+- **Reasoning**: St. John's Wort is a potent inducer of CYP3A4 and CYP2C9 hepatic enzymes — the primary metabolic pathways for warfarin. This enzyme induction accelerates warfarin metabolism, resulting in subtherapeutic INR levels and increased thromboembolic risk. The patient's INR of 1.6 (below therapeutic range of 2.0-3.0) is consistent with this interaction. This is a well-documented clinically significant drug-herb interaction. Option A describes the opposite effect. Option C incorrectly dismisses the interaction. Option D describes the wrong mechanism.
+
+### ASU-BASIC-001 -- CORRECT
+
+- **Selected**: C
+- **Correct**: True
+- **Confidence**: 94.0%
+- **Latency**: 0 ms
+- **Reasoning**: Post-surgical constipation is common due to anesthesia effects, opioid use, decreased mobility, and bowel manipulation. Gradual fiber increase (fruits, vegetables, whole grains), adequate hydration (8+ glasses daily), and early ambulation are first-line non-pharmacological interventions that promote bowel motility. Dairy products (A) can worsen constipation. Clear liquids only (B) provides inadequate fiber and nutrition. Red meat diet (D) without fiber worsens constipation. The key is 'gradually' — too rapid fiber increase can cause additional bloating.
+
+### ASU-BASIC-002 -- CORRECT
+
+- **Selected**: B
+- **Correct**: True
+- **Confidence**: 93.0%
+- **Latency**: 0 ms
+- **Reasoning**: A comprehensive nursing response addresses multiple concerns: (1) Pain at 7/10 warrants detailed assessment to rule out complications like dislocation, infection, or DVT. (2) Prolonged bed rest post-hip replacement increases DVT, pneumonia, and stiffness risk — prescribed mobility exercises are essential. (3) Uncontrolled pain despite scheduled acetaminophen warrants provider notification for medication adjustment. The nurse cannot independently recommend NSAIDs (C) without provider order. Bed rest (D) is contraindicated. Ice alone (A) is insufficient for 7/10 pain.
+
+### ASU-BASIC-003 -- CORRECT
+
+- **Selected**: C
+- **Correct**: True
+- **Confidence**: 91.0%
+- **Latency**: 0 ms
+- **Reasoning**: Some COPD patients develop hypoxic respiratory drive, meaning their breathing stimulus is triggered by low oxygen rather than high CO2. Excessive supplemental oxygen can suppress this drive, leading to hypoventilation, CO2 retention, and respiratory failure. Patients should not self-adjust oxygen flow rates. However, the nurse should not be alarmist (B). The appropriate response is education about the risk plus facilitating a provider consultation about activity-level oxygen needs, which may indeed warrant a higher prescribed rate for exertion.
+
+### ASU-RISK-001 -- CORRECT
+
+- **Selected**: C
+- **Correct**: True
+- **Confidence**: 94.0%
+- **Latency**: 0 ms
+- **Reasoning**: Hypokalemia (K+ 3.1, normal 3.5-5.0) in a patient on digoxin is the most urgent finding. Potassium and digoxin compete for the same binding site on the Na+/K+ ATPase pump — when potassium is low, more digoxin binds, intensifying its effect and significantly increasing the risk of fatal cardiac dysrhythmias. The digoxin level (1.8) is technically within range but effectively supratherapeutic with hypokalemia. Furosemide (loop diuretic) likely caused the potassium loss. The elevated creatinine (A) is concerning but less immediately dangerous. Option D incorrectly suggests all values are acceptable.
+
+### ASU-RISK-002 -- CORRECT
+
+- **Selected**: C
+- **Correct**: True
+- **Confidence**: 96.0%
+- **Latency**: 0 ms
+- **Reasoning**: Unilateral calf pain, swelling, warmth in a post-cesarean patient with immobility represents classic deep vein thrombosis (DVT) presentation. This patient has multiple Virchow's triad risk factors: venous stasis (immobility), endothelial injury (surgery), and hypercoagulability (postpartum state). DVT requires urgent evaluation with diagnostic ultrasound and potential anticoagulation. Calf massage (B) is strictly contraindicated — it could dislodge a clot causing fatal pulmonary embolism. Delayed assessment (D) risks PE. Warm compresses alone (A) fail to address urgency.
+
+### ASU-ADAPT-001 -- CORRECT
+
+- **Selected**: C
+- **Correct**: True
+- **Confidence**: 97.0%
+- **Latency**: 0 ms
+- **Reasoning**: The patient is presenting with classic recurrent diabetic ketoacidosis: severe hyperglycemia (420 mg/dL), polydipsia, polyuria, nausea, and fruity breath (ketone production). DKA is a life-threatening emergency requiring IV fluid resuscitation, continuous insulin infusion, and electrolyte monitoring in an acute care setting. Sliding-scale insulin at home (A) is insufficient for DKA. Fluids alone (B) cannot correct metabolic acidosis and insulin deficiency. Oral medications (D) are ineffective in DKA, and the patient is nauseated. This patient was just discharged for DKA — recurrence demands immediate emergency evaluation.
diff --git a/list/tenants/asu/pilot_documents/2025.12.13 FINAL Drive Health x ASU Health SOW and Budget.docx b/list/tenants/asu/pilot_documents/2025.12.13 FINAL Drive Health x ASU Health SOW and Budget.docx
new file mode 100644
index 0000000000000000000000000000000000000000..009ea9c6f067d026f131871dee12c07e367af1e8
--- /dev/null
+++ b/list/tenants/asu/pilot_documents/2025.12.13 FINAL Drive Health x ASU Health SOW and Budget.docx	
@@ -0,0 +1,3 @@
+version https://git-lfs.github.com/spec/v1
+oid sha256:cbbf1b1fdbc6c8d4ff4d39868b69692b7c2b238bfbd4cca22045d46a0489ecbb
+size 2683304
diff --git a/list/tenants/asu/pilot_documents/Brand review and recommendations for Drive Health (1).pdf b/list/tenants/asu/pilot_documents/Brand review and recommendations for Drive Health (1).pdf
new file mode 100644
index 0000000000000000000000000000000000000000..0bdf15054e4de661c65cd4223920a579a103fdba
--- /dev/null
+++ b/list/tenants/asu/pilot_documents/Brand review and recommendations for Drive Health (1).pdf	
@@ -0,0 +1,3 @@
+version https://git-lfs.github.com/spec/v1
+oid sha256:b9ff8a1029290768491260b1a5a4457cc8a82c54328065b7713f932a61203bcf
+size 863251
diff --git a/list/tenants/asu/pilot_documents/CLEAN_RPM One Inc. - 2025.12.18 ASU Drive Health Services Agreement.docx b/list/tenants/asu/pilot_documents/CLEAN_RPM One Inc. - 2025.12.18 ASU Drive Health Services Agreement.docx
new file mode 100644
index 0000000000000000000000000000000000000000..8b76955f24eb821437cae3a89d62c06819181750
--- /dev/null
+++ b/list/tenants/asu/pilot_documents/CLEAN_RPM One Inc. - 2025.12.18 ASU Drive Health Services Agreement.docx	
@@ -0,0 +1,3 @@
+version https://git-lfs.github.com/spec/v1
+oid sha256:3fe50a536433227a3de6510c79ef196158eb26ed18b4d2d250f916ad47706648
+size 53136
diff --git a/list/tenants/asu/sample_cases/care_transition.yaml b/list/tenants/asu/sample_cases/care_transition.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..508786b010504cc2199df31b0417043367eeac9a
--- /dev/null
+++ b/list/tenants/asu/sample_cases/care_transition.yaml
@@ -0,0 +1,51 @@
+cases:
+  # ── Care Transition: Pre-Op ──────────────────────────────────────────
+  - case_id: care_transition_preop_001
+    title: "Care Transition -- Pre-Op Assessment, Confused Patient"
+    case_type: care_transition
+    difficulty: hard
+    wedge: pre_op
+    domain: acute_illness_preop
+    risk_class: R2
+    cjm_stages_exercised:
+      - Recognize Cues
+      - Analyze Cues
+      - Prioritize Hypotheses
+      - Take Action
+    clinical_context: "78yo female, scheduled for knee replacement in 3 days, pre-op call"
+    turns:
+      - input_text: "Yes, I'm getting ready for my surgery"
+        expected_action: proceed
+      - input_text: "I've been feeling a bit off the last couple days"
+        expected_action: proceed
+        rationale: "Vague symptoms pre-op -- needs clarification"
+      - input_text: "I have a fever, about 101 degrees since yesterday"
+        expected_action: escalate
+        expected_risk_class: R2
+        check_domain: acute_illness_preop
+        cjm_stage: Prioritize Hypotheses
+        is_critical: true
+        rationale: "Fever before scheduled surgery requires escalation to surgical team"
+    expected_final_outcome: escalate
+    tags: [pre_op, fever, care_transition, r2]
+
+  - case_id: care_transition_preop_routine_002
+    title: "Care Transition -- Routine Pre-Op, No Issues"
+    case_type: care_transition
+    difficulty: easy
+    wedge: pre_op
+    domain: acute_illness_preop
+    risk_class: R0
+    cjm_stages_exercised:
+      - Recognize Cues
+      - Evaluate Outcomes
+    clinical_context: "50yo male, scheduled for hernia repair, routine pre-op call"
+    turns:
+      - input_text: "Yes, I'm ready for my surgery next week"
+        expected_action: proceed
+      - input_text: "No, I haven't been sick at all, feeling fine"
+        expected_action: proceed
+      - input_text: "I stopped my blood thinner like the doctor said"
+        expected_action: proceed
+    expected_final_outcome: proceed
+    tags: [pre_op, routine, care_transition]
diff --git a/list/tenants/asu/sample_cases/discharge_followup.yaml b/list/tenants/asu/sample_cases/discharge_followup.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..490d2911f90dfb879c06937f3f4880a7f8ffd64b
--- /dev/null
+++ b/list/tenants/asu/sample_cases/discharge_followup.yaml
@@ -0,0 +1,79 @@
+cases:
+  # ── Discharge Follow-up: Medication Barriers ─────────────────────────
+  - case_id: discharge_med_barrier_001
+    title: "Discharge Follow-up -- Medication Cost Barrier"
+    case_type: discharge
+    difficulty: medium
+    wedge: pde
+    domain: post_discharge_engagement
+    risk_class: R0
+    cjm_stages_exercised:
+      - Recognize Cues
+      - Analyze Cues
+      - Generate Solutions
+    clinical_context: "68yo male, discharged 3 days ago for CHF, follow-up call"
+    turns:
+      - input_text: "I'm doing okay since I got home"
+        expected_action: proceed
+      - input_text: "Well, I haven't been able to get my new heart medication yet"
+        expected_action: proceed
+        rationale: "Medication non-adherence disclosure -- barrier identification"
+      - input_text: "It's too expensive, the pharmacy said it would be $200"
+        expected_action: proceed
+        rationale: "Cost barrier identified -- engine should classify barrier"
+      - input_text: "No one told me about any financial help programs"
+        expected_action: proceed
+    expected_final_outcome: proceed
+    tags: [discharge, medication, cost_barrier, pde]
+
+  - case_id: discharge_pain_escalation_002
+    title: "Discharge Follow-up -- Worsening Surgical Pain"
+    case_type: discharge
+    difficulty: hard
+    wedge: pde
+    domain: post_discharge_engagement
+    risk_class: R2
+    cjm_stages_exercised:
+      - Recognize Cues
+      - Analyze Cues
+      - Prioritize Hypotheses
+      - Take Action
+    clinical_context: "55yo female, post-appendectomy day 5, follow-up call"
+    turns:
+      - input_text: "Things were getting better but now my pain is worse"
+        expected_action: proceed
+      - input_text: "The pain is around my incision, it's really red and swollen"
+        expected_action: escalate
+        expected_risk_class: R2
+        check_domain: wound_complication
+        cjm_stage: Prioritize Hypotheses
+        is_critical: true
+        rationale: "Wound redness and swelling post-op suggests infection -- R2 escalation"
+      - input_text: "I also noticed some drainage from the wound"
+        expected_action: escalate
+        expected_risk_class: R2
+        is_critical: true
+        rationale: "Wound drainage confirms surgical site concern -- R2 must persist"
+    expected_final_outcome: escalate
+    tags: [discharge, wound, pain, r2, pde]
+
+  - case_id: discharge_routine_003
+    title: "Discharge Follow-up -- Routine Check-in, No Concerns"
+    case_type: followup_checkin
+    difficulty: easy
+    wedge: pde
+    domain: post_discharge_engagement
+    risk_class: R0
+    cjm_stages_exercised:
+      - Recognize Cues
+      - Evaluate Outcomes
+    clinical_context: "42yo male, discharged 2 days ago for minor procedure, routine follow-up"
+    turns:
+      - input_text: "I'm feeling much better, thanks for calling"
+        expected_action: proceed
+      - input_text: "I've been taking all my medications as directed"
+        expected_action: proceed
+      - input_text: "No pain, no swelling, everything looks good"
+        expected_action: proceed
+    expected_final_outcome: proceed
+    tags: [discharge, routine, no_concerns, pde]
diff --git a/list/tenants/asu/sample_cases/medication_education.yaml b/list/tenants/asu/sample_cases/medication_education.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..7d96abd913c4be5e6df67b519faec28ddf5e4f6d
--- /dev/null
+++ b/list/tenants/asu/sample_cases/medication_education.yaml
@@ -0,0 +1,81 @@
+cases:
+  # ── Medication Education: Insulin Teaching ───────────────────────────
+  - case_id: med_edu_insulin_001
+    title: "Medication Education -- New Insulin Start"
+    case_type: medication_education
+    difficulty: medium
+    wedge: pde
+    domain: post_discharge_engagement
+    risk_class: R0
+    cjm_stages_exercised:
+      - Recognize Cues
+      - Generate Solutions
+      - Evaluate Outcomes
+    clinical_context: "60yo female, newly started on insulin, education call about administration"
+    turns:
+      - input_text: "I just started insulin and I'm nervous about giving myself shots"
+        expected_action: proceed
+      - input_text: "The nurse showed me how to inject in my belly"
+        expected_action: proceed
+      - input_text: "I rotate the injection sites like they told me"
+        expected_action: proceed
+        rationale: "Patient demonstrates injection site rotation knowledge"
+      - input_text: "I know to check my blood sugar before meals"
+        expected_action: proceed
+    expected_final_outcome: proceed
+    tags: [medication, insulin, education, pde]
+
+  - case_id: med_edu_hypoglycemia_002
+    title: "Medication Education -- Active Hypoglycemia During Call"
+    case_type: medication_education
+    difficulty: hard
+    wedge: pde
+    domain: post_discharge_engagement
+    risk_class: R3
+    cjm_stages_exercised:
+      - Recognize Cues
+      - Prioritize Hypotheses
+      - Take Action
+    clinical_context: "55yo male, on insulin, develops hypoglycemia symptoms during education call"
+    turns:
+      - input_text: "I wanted to ask about adjusting my insulin dose"
+        expected_action: proceed
+      - input_text: "Actually I'm feeling kind of shaky and sweaty right now"
+        expected_action: escalate
+        expected_risk_class: R3
+        check_domain: severe_hypoglycemia
+        cjm_stage: Recognize Cues
+        is_critical: true
+        rationale: "Shaky and sweaty in diabetic on insulin = hypoglycemia -- R3"
+      - input_text: "I feel dizzy and my hands are trembling"
+        expected_action: escalate
+        expected_risk_class: R3
+        is_critical: true
+        rationale: "Worsening hypoglycemia symptoms -- R3 must persist"
+    expected_final_outcome: escalate
+    tags: [medication, insulin, hypoglycemia, r3, safety_escalation, pde]
+
+  - case_id: med_edu_side_effects_003
+    title: "Medication Education -- Medication Side Effect Concern"
+    case_type: medication_education
+    difficulty: medium
+    wedge: pde
+    domain: post_discharge_engagement
+    risk_class: R0
+    cjm_stages_exercised:
+      - Recognize Cues
+      - Analyze Cues
+      - Generate Solutions
+    clinical_context: "48yo female, started new BP medication, reports mild side effects"
+    turns:
+      - input_text: "I started that new blood pressure pill last week"
+        expected_action: proceed
+      - input_text: "I've been a little dizzy when I stand up too fast"
+        expected_action: proceed
+        rationale: "Orthostatic symptoms from new BP med -- common, not urgent"
+      - input_text: "It only lasts a few seconds and then I'm fine"
+        expected_action: proceed
+      - input_text: "I'll mention it at my follow-up appointment"
+        expected_action: proceed
+    expected_final_outcome: proceed
+    tags: [medication, side_effects, blood_pressure, pde]
diff --git a/list/tenants/asu/sample_cases/patient_education.yaml b/list/tenants/asu/sample_cases/patient_education.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..d966684576a51e2910fd6c14475eb40b88801f7a
--- /dev/null
+++ b/list/tenants/asu/sample_cases/patient_education.yaml
@@ -0,0 +1,103 @@
+cases:
+  # ── Patient Education: COPD ──────────────────────────────────────────
+  - case_id: copd_edu_basic_001
+    title: "COPD Education -- Basic Inhaler Teaching"
+    case_type: patient_education
+    difficulty: easy
+    wedge: sim_education
+    domain: copd_education
+    risk_class: R0
+    cjm_stages_exercised:
+      - Recognize Cues
+      - Generate Solutions
+    clinical_context: "65yo male, newly diagnosed COPD, education call about inhaler use"
+    turns:
+      - input_text: "Hi, yes I'd like to learn about my inhalers"
+        expected_action: proceed
+      - input_text: "I have a rescue inhaler and a maintenance one"
+        expected_action: proceed
+      - input_text: "So I use the maintenance one every day and the rescue one when I need it?"
+        expected_action: proceed
+        rationale: "Patient demonstrates understanding of inhaler regimen"
+    expected_final_outcome: proceed
+    tags: [copd, inhaler, education]
+
+  - case_id: copd_edu_smoking_002
+    title: "COPD Education -- Smoking Cessation Discussion"
+    case_type: patient_education
+    difficulty: medium
+    wedge: sim_education
+    domain: copd_education
+    risk_class: R0
+    cjm_stages_exercised:
+      - Recognize Cues
+      - Analyze Cues
+      - Generate Solutions
+    clinical_context: "58yo female, COPD, still smoking, education about cessation"
+    turns:
+      - input_text: "Yes, I know I should quit smoking"
+        expected_action: proceed
+      - input_text: "I've tried patches before but they didn't work"
+        expected_action: proceed
+      - input_text: "Maybe I could try the nicotine gum instead"
+        expected_action: proceed
+        rationale: "Patient shows readiness to explore alternatives"
+      - input_text: "I'll talk to my doctor about other options"
+        expected_action: proceed
+    expected_final_outcome: proceed
+    tags: [copd, smoking_cessation, education]
+
+  - case_id: copd_edu_escalation_003
+    title: "COPD Education -- Mid-Call Respiratory Distress"
+    case_type: patient_education
+    difficulty: hard
+    wedge: sim_education
+    domain: copd_education
+    risk_class: R3
+    cjm_stages_exercised:
+      - Recognize Cues
+      - Prioritize Hypotheses
+      - Take Action
+    clinical_context: "72yo female, known COPD, education call interrupted by acute symptoms"
+    turns:
+      - input_text: "Hello, yes I want to learn more about managing my COPD"
+        expected_action: proceed
+      - input_text: "I understand I need to use my inhalers regularly"
+        expected_action: proceed
+      - input_text: "Hold on... I'm having a really hard time breathing right now"
+        expected_action: escalate
+        expected_risk_class: R3
+        check_domain: shortness_of_breath_rest
+        cjm_stage: Prioritize Hypotheses
+        is_critical: true
+        rationale: "Acute SOB at rest during call requires immediate escalation"
+      - input_text: "It started about 10 minutes ago and it's getting worse"
+        expected_action: escalate
+        expected_risk_class: R3
+        is_critical: true
+        rationale: "Worsening SOB confirms R3 -- escalation must persist"
+    expected_final_outcome: escalate
+    tags: [copd, safety_escalation, r3, shortness_of_breath]
+
+  # ── Patient Education: DVT ───────────────────────────────────────────
+  - case_id: dvt_edu_basic_004
+    title: "DVT Education -- Anticoagulation Teaching"
+    case_type: patient_education
+    difficulty: easy
+    wedge: sim_education
+    domain: dvt_education
+    risk_class: R0
+    cjm_stages_exercised:
+      - Recognize Cues
+      - Generate Solutions
+    clinical_context: "45yo male, recent DVT, education about anticoagulation therapy"
+    turns:
+      - input_text: "Yes, I want to understand my blood thinner medication"
+        expected_action: proceed
+      - input_text: "I take it once a day in the morning"
+        expected_action: proceed
+      - input_text: "I know I should avoid contact sports and be careful about cuts"
+        expected_action: proceed
+        rationale: "Patient demonstrates bleeding precaution awareness"
+    expected_final_outcome: proceed
+    tags: [dvt, anticoagulation, education]
diff --git a/list/tenants/asu/sample_cases/safety_escalation.yaml b/list/tenants/asu/sample_cases/safety_escalation.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..86760498230f9e9d78b2e9c911bc967f1d1b6b48
--- /dev/null
+++ b/list/tenants/asu/sample_cases/safety_escalation.yaml
@@ -0,0 +1,65 @@
+cases:
+  # ── Safety Escalation: Chest Pain During Education ───────────────────
+  - case_id: safety_chest_pain_001
+    title: "Safety Escalation -- Chest Pain During DVT Education"
+    case_type: patient_education
+    difficulty: hard
+    wedge: sim_education
+    domain: dvt_education
+    risk_class: R3
+    cjm_stages_exercised:
+      - Recognize Cues
+      - Prioritize Hypotheses
+      - Take Action
+    clinical_context: "52yo male, recent DVT, education call -- develops chest pain (possible PE)"
+    turns:
+      - input_text: "Yes, I want to learn about my blood clot"
+        expected_action: proceed
+      - input_text: "I understand I need to take my blood thinner every day"
+        expected_action: proceed
+      - input_text: "Wait, I'm getting this sharp pain in my chest when I breathe"
+        expected_action: escalate
+        expected_risk_class: R3
+        check_domain: chest_pain
+        cjm_stage: Prioritize Hypotheses
+        is_critical: true
+        rationale: "Pleuritic chest pain in DVT patient = PE concern -- R3 immediate escalation"
+      - input_text: "It hurts more when I take a deep breath"
+        expected_action: escalate
+        expected_risk_class: R3
+        is_critical: true
+        rationale: "Worsening pleuritic chest pain -- R3 must persist"
+    expected_final_outcome: escalate
+    tags: [safety, chest_pain, dvt, pe, r3]
+
+  - case_id: safety_stroke_symptoms_002
+    title: "Safety Escalation -- Stroke Symptoms During Follow-up"
+    case_type: followup_checkin
+    difficulty: hard
+    wedge: pde
+    domain: post_discharge_engagement
+    risk_class: R3
+    cjm_stages_exercised:
+      - Recognize Cues
+      - Prioritize Hypotheses
+      - Take Action
+    clinical_context: "70yo male, discharged after cardiac procedure, develops sudden neuro symptoms"
+    turns:
+      - input_text: "I've been doing pretty well since I got home"
+        expected_action: proceed
+      - input_text: "But right now something weird is happening with my face"
+        expected_action: proceed
+        rationale: "Vague facial complaint -- needs more information"
+      - input_text: "One side of my face feels numb and droopy, and my arm feels weak"
+        expected_action: escalate
+        expected_risk_class: R3
+        check_domain: stroke_symptoms
+        cjm_stage: Prioritize Hypotheses
+        is_critical: true
+        rationale: "Facial droop + arm weakness = classic stroke presentation -- R3"
+      - input_text: "It just started a few minutes ago"
+        expected_action: escalate
+        expected_risk_class: R3
+        is_critical: true
+    expected_final_outcome: escalate
+    tags: [safety, stroke, r3, pde]
diff --git a/list/tenants/asu/sample_questions/claude_answers.json b/list/tenants/asu/sample_questions/claude_answers.json
new file mode 100644
index 0000000000000000000000000000000000000000..382c71eac34b4fa10e8735c5623ae8b8e831c5de
--- /dev/null
+++ b/list/tenants/asu/sample_questions/claude_answers.json
@@ -0,0 +1,107 @@
+{
+  "ASU-MGMT-001": {
+    "selected_answer": "B",
+    "reasoning": "Before implementing any intervention, the nurse must first assess the patient's baseline understanding and learning readiness. The teach-back method is an evidence-based assessment approach that evaluates comprehension by having patients explain information in their own words. This assessment should precede all other discharge planning activities because the patient's health literacy level will determine how to structure subsequent education. Written materials (A), appointments (C), and home health (D) are all appropriate but secondary to initial assessment.",
+    "confidence": 0.95
+  },
+  "ASU-MGMT-002": {
+    "selected_answer": "B",
+    "reasoning": "Patient-centered care and therapeutic communication principles require acknowledging the patient's experience before taking clinical action. The patient made a self-directed decision to stop a medication due to a real side effect. Assessing the impact of fatigue on daily activities gathers essential data to inform the next step — whether to encourage adherence, contact the provider for an alternative, or explore timing adjustments. Instructing to resume (A) ignores the patient's autonomy. Risk education (C) may come across as fear-based. Contacting the provider (D) is premature without full assessment.",
+    "confidence": 0.92
+  },
+  "ASU-MGMT-003": {
+    "selected_answer": "B",
+    "reasoning": "Chest pain radiating to the left arm with diaphoresis represents classic acute myocardial infarction presentation, which is a life-threatening emergency requiring immediate EMS activation. The UAP cannot perform further clinical assessment (A), as this exceeds their scope. A 15-minute delay (C) could be fatal. Medication administration such as aspirin (D) cannot be delegated to a UAP and requires nursing clinical judgment. The nurse must direct the UAP to call 911 immediately while staying with the patient.",
+    "confidence": 0.97
+  },
+  "ASU-MGMT-004": {
+    "selected_answer": "C",
+    "reasoning": "Using the ABCs and priority-setting framework: the patient 1 day post-cardiac catheterization with numbness and coolness in the affected extremity shows signs of arterial occlusion or thrombosis — a vascular emergency that can result in limb loss if not addressed immediately. This is a perfusion/circulation issue that takes priority. The post-appendectomy patient (A) has signs of infection requiring timely but not emergent response. The opioid refill (B) and post-cholecystectomy nausea (D) are lower acuity. Circulation threats rank highest in triage priority.",
+    "confidence": 0.93
+  },
+  "ASU-SAFE-001": {
+    "selected_answer": "B",
+    "reasoning": "For fall prevention in an elderly post-hip fracture patient with orthostatic dizziness, environmental hazard modification is the highest-priority intervention. Throw rugs are a leading cause of falls in the elderly and represent an immediately modifiable risk factor. While orthostatic precautions (D), exercise programs (A), and toileting modifications (C) are all appropriate, removing the most immediate environmental hazard takes precedence. The patient has demonstrated fall risk with the hip fracture history and has a correctable home hazard.",
+    "confidence": 0.91
+  },
+  "ASU-SAFE-002": {
+    "selected_answer": "C",
+    "reasoning": "Redness, warmth, purulent drainage at a central venous catheter site combined with fever (100.8F) are hallmark signs of catheter-related bloodstream infection (CRBSI), which can rapidly progress to sepsis. This requires immediate medical evaluation including blood cultures, possible catheter removal by a qualified provider, and initiation of IV antibiotics. Home management with dressing changes (A) or warm compresses (B) is insufficient and dangerous. The patient should never self-remove a central venous catheter (D). CRBSI has significant morbidity and mortality requiring urgent intervention.",
+    "confidence": 0.96
+  },
+  "ASU-SAFE-003": {
+    "selected_answer": "C",
+    "reasoning": "This is a 'need for further teaching' question, so the incorrect statement is the answer. Ibuprofen (an NSAID) is contraindicated with warfarin because NSAIDs have antiplatelet effects and can increase INR, significantly raising bleeding risk. Patients on warfarin should use acetaminophen for pain relief instead. Options A (electric razor), B (regular INR monitoring), and D (reporting unusual bleeding) all demonstrate correct understanding of warfarin safety precautions.",
+    "confidence": 0.97
+  },
+  "ASU-HPM-001": {
+    "selected_answer": "B",
+    "reasoning": "Evidence-based health promotion requires providing accurate, current guideline information tailored to the patient's individual risk factors. USPSTF recommends colorectal cancer screening beginning at age 45 for average-risk adults, and a first-degree family history of colon cancer is a significant risk factor per ACS guidelines. This response is informative, non-judgmental, and personalized. Option A is dismissive. Option C is directive without education. Option D is misleading because stool-based tests are not equivalent to colonoscopy for high-risk patients with family history.",
+    "confidence": 0.90
+  },
+  "ASU-HPM-002": {
+    "selected_answer": "B",
+    "reasoning": "This response directly answers the patient's 'why' question with a pathophysiological explanation. Diabetic peripheral neuropathy results from chronic hyperglycemia damaging peripheral nerves, causing decreased sensation in the feet. Combined with peripheral vascular disease that impairs healing, undetected injuries can progress to ulceration, infection, and potentially amputation. Explaining the mechanism promotes understanding and adherence to self-care. Options A and C use authoritarian approaches without education. Option D is factually inaccurate about the primary mechanism.",
+    "confidence": 0.95
+  },
+  "ASU-HPM-003": {
+    "selected_answer": "B",
+    "reasoning": "Per current CDC/ACIP guidelines, adults aged 65+ who receive PCV20 (Prevnar 20) do not need additional pneumococcal vaccines. PCV20 provides comprehensive coverage of all 20 serotypes, including those in both PCV15 and PPSV23. The previous PCV15 + PPSV23 pathway was an alternative, but PCV20 alone is sufficient and complete. PPSV23 after PCV20 (A) is unnecessary. PCV15 booster (C) would be redundant. Pneumococcal vaccines are not repeated on a regular schedule (D).",
+    "confidence": 0.88
+  },
+  "ASU-PSY-001": {
+    "selected_answer": "C",
+    "reasoning": "This response uses two key therapeutic communication techniques: reflection (acknowledging the emotional content) and open-ended questioning (inviting elaboration). The patient's statement — 'I don't see the point in taking medications anymore. Nothing matters.' — could indicate grief, depression, or suicidal ideation. Further assessment is essential before taking action. Option A makes assumptions about the spouse. Option B dismisses emotions and focuses only on compliance. Option D jumps to intervention without assessment. The nurse must first explore whether the patient is expressing grief, hopelessness, or suicidal thoughts.",
+    "confidence": 0.94
+  },
+  "ASU-PSY-002": {
+    "selected_answer": "C",
+    "reasoning": "This response validates the patient's feelings of loss and frustration while redirecting toward goal-setting and rehabilitation priorities. It demonstrates empathetic listening and a strengths-based approach by focusing on what the patient wants to achieve. Option A offers false reassurance. Option B speaks for the family and dismisses the patient's feelings. Option D jumps to a practical solution without addressing emotional needs or rehabilitation goals. Addressing the psychosocial impact of functional loss is essential for rehabilitation engagement.",
+    "confidence": 0.93
+  },
+  "ASU-PHARM-001": {
+    "selected_answer": "B",
+    "reasoning": "Metformin should be taken with meals to minimize the most common side effects: nausea, diarrhea, and abdominal discomfort. The twice-daily dosing should be aligned with the two largest meals for optimal absorption and GI tolerability. Empty stomach (A) significantly worsens GI side effects and is a leading cause of discontinuation. Bedtime (C) is not standard for immediate-release metformin. Combining both doses (D) defeats the purpose of twice-daily dosing and increases side effect risk.",
+    "confidence": 0.95
+  },
+  "ASU-PHARM-002": {
+    "selected_answer": "C",
+    "reasoning": "A persistent dry cough is a well-known class effect of ACE inhibitors like lisinopril, caused by bradykinin accumulation in the lungs. It occurs in 5-20% of patients. The nurse should document this as a potential adverse drug reaction and notify the prescriber, who may switch to an ARB. The nurse should not independently discontinue an antihypertensive (B) or dismiss the symptom (A, D). An OTC cough suppressant will not resolve an ACE inhibitor-induced cough. The prescriber needs to make the medication change decision.",
+    "confidence": 0.95
+  },
+  "ASU-PHARM-003": {
+    "selected_answer": "B",
+    "reasoning": "St. John's Wort is a potent inducer of CYP3A4 and CYP2C9 hepatic enzymes — the primary metabolic pathways for warfarin. This enzyme induction accelerates warfarin metabolism, resulting in subtherapeutic INR levels and increased thromboembolic risk. The patient's INR of 1.6 (below therapeutic range of 2.0-3.0) is consistent with this interaction. This is a well-documented clinically significant drug-herb interaction. Option A describes the opposite effect. Option C incorrectly dismisses the interaction. Option D describes the wrong mechanism.",
+    "confidence": 0.92
+  },
+  "ASU-BASIC-001": {
+    "selected_answer": "C",
+    "reasoning": "Post-surgical constipation is common due to anesthesia effects, opioid use, decreased mobility, and bowel manipulation. Gradual fiber increase (fruits, vegetables, whole grains), adequate hydration (8+ glasses daily), and early ambulation are first-line non-pharmacological interventions that promote bowel motility. Dairy products (A) can worsen constipation. Clear liquids only (B) provides inadequate fiber and nutrition. Red meat diet (D) without fiber worsens constipation. The key is 'gradually' — too rapid fiber increase can cause additional bloating.",
+    "confidence": 0.94
+  },
+  "ASU-BASIC-002": {
+    "selected_answer": "B",
+    "reasoning": "A comprehensive nursing response addresses multiple concerns: (1) Pain at 7/10 warrants detailed assessment to rule out complications like dislocation, infection, or DVT. (2) Prolonged bed rest post-hip replacement increases DVT, pneumonia, and stiffness risk — prescribed mobility exercises are essential. (3) Uncontrolled pain despite scheduled acetaminophen warrants provider notification for medication adjustment. The nurse cannot independently recommend NSAIDs (C) without provider order. Bed rest (D) is contraindicated. Ice alone (A) is insufficient for 7/10 pain.",
+    "confidence": 0.93
+  },
+  "ASU-BASIC-003": {
+    "selected_answer": "C",
+    "reasoning": "Some COPD patients develop hypoxic respiratory drive, meaning their breathing stimulus is triggered by low oxygen rather than high CO2. Excessive supplemental oxygen can suppress this drive, leading to hypoventilation, CO2 retention, and respiratory failure. Patients should not self-adjust oxygen flow rates. However, the nurse should not be alarmist (B). The appropriate response is education about the risk plus facilitating a provider consultation about activity-level oxygen needs, which may indeed warrant a higher prescribed rate for exertion.",
+    "confidence": 0.91
+  },
+  "ASU-RISK-001": {
+    "selected_answer": "C",
+    "reasoning": "Hypokalemia (K+ 3.1, normal 3.5-5.0) in a patient on digoxin is the most urgent finding. Potassium and digoxin compete for the same binding site on the Na+/K+ ATPase pump — when potassium is low, more digoxin binds, intensifying its effect and significantly increasing the risk of fatal cardiac dysrhythmias. The digoxin level (1.8) is technically within range but effectively supratherapeutic with hypokalemia. Furosemide (loop diuretic) likely caused the potassium loss. The elevated creatinine (A) is concerning but less immediately dangerous. Option D incorrectly suggests all values are acceptable.",
+    "confidence": 0.94
+  },
+  "ASU-RISK-002": {
+    "selected_answer": "C",
+    "reasoning": "Unilateral calf pain, swelling, warmth in a post-cesarean patient with immobility represents classic deep vein thrombosis (DVT) presentation. This patient has multiple Virchow's triad risk factors: venous stasis (immobility), endothelial injury (surgery), and hypercoagulability (postpartum state). DVT requires urgent evaluation with diagnostic ultrasound and potential anticoagulation. Calf massage (B) is strictly contraindicated — it could dislodge a clot causing fatal pulmonary embolism. Delayed assessment (D) risks PE. Warm compresses alone (A) fail to address urgency.",
+    "confidence": 0.96
+  },
+  "ASU-ADAPT-001": {
+    "selected_answer": "C",
+    "reasoning": "The patient is presenting with classic recurrent diabetic ketoacidosis: severe hyperglycemia (420 mg/dL), polydipsia, polyuria, nausea, and fruity breath (ketone production). DKA is a life-threatening emergency requiring IV fluid resuscitation, continuous insulin infusion, and electrolyte monitoring in an acute care setting. Sliding-scale insulin at home (A) is insufficient for DKA. Fluids alone (B) cannot correct metabolic acidosis and insulin deficiency. Oral medications (D) are ineffective in DKA, and the patient is nauseated. This patient was just discharged for DKA — recurrence demands immediate emergency evaluation.",
+    "confidence": 0.97
+  }
+}
diff --git a/list/tenants/asu/sample_questions/nclex_sample_bank.json b/list/tenants/asu/sample_questions/nclex_sample_bank.json
new file mode 100644
index 0000000000000000000000000000000000000000..857861aacc01fcddf04e850c74616c05304986dd
--- /dev/null
+++ b/list/tenants/asu/sample_questions/nclex_sample_bank.json
@@ -0,0 +1,408 @@
+{
+  "bank_id": "asu_nclex_sample_v1",
+  "name": "ASU College of Nursing NCLEX Sample Bank",
+  "description": "Sample NCLEX-RN style questions aligned with the ASU SOW scope: patient education, care transitions, discharge planning, medication education, and follow-up check-ins. Covers all eight NCLEX Client Needs subcategories with emphasis on telephonic nursing competencies.",
+  "version": "1.0",
+  "created_at": "2026-03-01",
+  "questions": [
+    {
+      "question_id": "ASU-MGMT-001",
+      "stem": "A nurse is preparing discharge instructions for a patient with newly diagnosed heart failure. The patient lives alone and has limited health literacy. Which action should the nurse prioritize first?",
+      "options": {
+        "A": "Provide a comprehensive written packet covering all aspects of heart failure management",
+        "B": "Assess the patient's understanding of their diagnosis using teach-back method",
+        "C": "Schedule a follow-up appointment with the cardiologist within 7 days",
+        "D": "Arrange for home health nursing visits three times per week"
+      },
+      "correct_answer": "B",
+      "rationale": "Before implementing any teaching strategy, the nurse must first assess the patient's current understanding and readiness to learn. The teach-back method is an evidence-based approach that verifies comprehension by asking patients to explain information in their own words. This assessment informs all subsequent discharge planning decisions. While the other options are appropriate interventions, they should follow the initial assessment of learning needs.",
+      "category": "Safe and Effective Care Environment",
+      "subcategory": "Management of Care",
+      "cognitive_level": "analyze",
+      "clinical_judgment_stage": "Prioritize Hypotheses",
+      "difficulty": "medium",
+      "tags": ["discharge_planning", "heart_failure", "health_literacy", "teach_back", "patient_education"],
+      "source": "ASU CON Simulation Lab"
+    },
+    {
+      "question_id": "ASU-MGMT-002",
+      "stem": "During a post-discharge follow-up call, a patient reports they stopped taking their prescribed beta-blocker because it makes them feel tired. The patient's blood pressure was 158/94 mmHg at their last visit. What is the nurse's most appropriate initial response?",
+      "options": {
+        "A": "Instruct the patient to resume the medication immediately and report side effects to the provider",
+        "B": "Acknowledge the patient's concern and assess the impact of fatigue on their daily activities",
+        "C": "Explain the risks of uncontrolled hypertension including stroke and heart attack",
+        "D": "Contact the prescribing provider to request an alternative medication"
+      },
+      "correct_answer": "B",
+      "rationale": "Therapeutic communication and patient-centered care require the nurse to first acknowledge the patient's experience and gather more information before taking action. Assessing the impact of the side effect helps determine the appropriate next step. Simply telling the patient to resume medication ignores their concern and may decrease adherence further. While contacting the provider may be necessary, it should follow a thorough assessment. Education about risks is important but should not be the first response when a patient has already made a decision based on side effects.",
+      "category": "Safe and Effective Care Environment",
+      "subcategory": "Management of Care",
+      "cognitive_level": "apply",
+      "clinical_judgment_stage": "Recognize Cues",
+      "difficulty": "medium",
+      "tags": ["medication_adherence", "therapeutic_communication", "hypertension", "follow_up", "beta_blocker"],
+      "source": "ASU CON Simulation Lab"
+    },
+    {
+      "question_id": "ASU-MGMT-003",
+      "stem": "A nurse receives a call from an unlicensed assistive personnel (UAP) who is conducting a post-discharge wellness check. The UAP reports that the patient is complaining of new-onset chest pain radiating to the left arm and is diaphoretic. Which delegation decision is most appropriate?",
+      "options": {
+        "A": "Instruct the UAP to continue the assessment and document findings",
+        "B": "Direct the UAP to call 911 immediately and stay with the patient until help arrives",
+        "C": "Ask the UAP to take the patient's vital signs and report back in 15 minutes",
+        "D": "Tell the UAP to have the patient take an aspirin and rest in a recumbent position"
+      },
+      "correct_answer": "B",
+      "rationale": "The symptoms described (chest pain radiating to the left arm with diaphoresis) are classic signs of a myocardial infarction requiring immediate emergency intervention. The nurse must direct the UAP to activate emergency medical services (911) immediately. Assessment, medication administration, and clinical decision-making cannot be delegated to UAPs. A 15-minute delay could be fatal in an acute MI. While aspirin may be appropriate, medication administration requires nursing judgment and cannot be delegated.",
+      "category": "Safe and Effective Care Environment",
+      "subcategory": "Management of Care",
+      "cognitive_level": "analyze",
+      "clinical_judgment_stage": "Take Action",
+      "difficulty": "medium",
+      "tags": ["delegation", "emergency_response", "chest_pain", "uap", "myocardial_infarction"],
+      "source": "ASU CON Simulation Lab"
+    },
+    {
+      "question_id": "ASU-MGMT-004",
+      "stem": "A nurse is triaging four post-discharge follow-up calls. Which patient should the nurse call back first?",
+      "options": {
+        "A": "A patient 2 days post-appendectomy reporting incisional redness and a temperature of 101.2F (38.4C)",
+        "B": "A patient 5 days post-total knee replacement requesting a refill on their prescribed opioid analgesic",
+        "C": "A patient 1 day post-cardiac catheterization reporting numbness and coolness in the affected extremity",
+        "D": "A patient 3 days post-cholecystectomy reporting mild nausea after eating a high-fat meal"
+      },
+      "correct_answer": "C",
+      "rationale": "Numbness and coolness in the extremity used for cardiac catheterization access are signs of arterial occlusion or thrombosis, which is a vascular emergency requiring immediate assessment and intervention. Loss of circulation to the extremity can lead to tissue ischemia and potential limb loss if not addressed promptly. While the post-appendectomy patient with fever and redness needs timely follow-up for possible surgical site infection, it is not as immediately life- or limb-threatening. The opioid refill and post-cholecystectomy nausea are lower priority.",
+      "category": "Safe and Effective Care Environment",
+      "subcategory": "Management of Care",
+      "cognitive_level": "analyze",
+      "clinical_judgment_stage": "Prioritize Hypotheses",
+      "difficulty": "hard",
+      "tags": ["prioritization", "triage", "cardiac_catheterization", "vascular_emergency", "post_discharge"],
+      "source": "ASU CON Simulation Lab"
+    },
+    {
+      "question_id": "ASU-SAFE-001",
+      "stem": "A nurse is conducting a post-discharge phone call with an elderly patient who was hospitalized for a hip fracture repair. The patient reports feeling dizzy when standing up and mentions they have throw rugs throughout their home. Which intervention is the highest priority to discuss?",
+      "options": {
+        "A": "Recommend the patient begin a supervised exercise program to improve balance",
+        "B": "Advise the patient to remove all throw rugs and ensure adequate lighting in walkways",
+        "C": "Suggest the patient use a bedside commode to avoid walking to the bathroom at night",
+        "D": "Instruct the patient to rise slowly from a seated position and wait before walking"
+      },
+      "correct_answer": "B",
+      "rationale": "Environmental hazard modification is the highest priority fall prevention intervention for this patient. Throw rugs are a leading cause of falls in the elderly and represent an immediately modifiable risk factor. While orthostatic precautions (option D), exercise programs (option A), and toileting modifications (option C) are all appropriate fall prevention strategies, removing environmental hazards addresses the most immediate and easily correctable risk. The patient has already demonstrated fall risk with the hip fracture history and reported orthostatic dizziness.",
+      "category": "Safe and Effective Care Environment",
+      "subcategory": "Safety and Infection Control",
+      "cognitive_level": "apply",
+      "clinical_judgment_stage": "Generate Solutions",
+      "difficulty": "easy",
+      "tags": ["fall_prevention", "elderly", "home_safety", "hip_fracture", "post_discharge"],
+      "source": "ASU CON Simulation Lab"
+    },
+    {
+      "question_id": "ASU-SAFE-002",
+      "stem": "During a telehealth follow-up, a patient who had a central venous catheter placed for chemotherapy reports redness, warmth, and purulent drainage at the insertion site. Their temperature is 100.8F (38.2C). What should the nurse instruct the patient to do?",
+      "options": {
+        "A": "Clean the site with chlorhexidine, apply a new sterile dressing, and monitor for 24 hours",
+        "B": "Apply warm compresses to the site and take acetaminophen for the fever",
+        "C": "Seek immediate medical evaluation, as these are signs of a catheter-related bloodstream infection",
+        "D": "Remove the central venous catheter and apply pressure to the site"
+      },
+      "correct_answer": "C",
+      "rationale": "Redness, warmth, purulent drainage, and fever at a central venous catheter site are hallmark signs of a catheter-related bloodstream infection (CRBSI), which can rapidly progress to sepsis. This requires immediate medical evaluation for blood cultures, possible catheter removal by a qualified provider, and initiation of IV antibiotics. The patient should not attempt to manage this at home or remove the catheter themselves. A 24-hour monitoring period is inappropriate given the risk of septic progression. CRBSIs are a serious healthcare-associated infection with significant morbidity and mortality.",
+      "category": "Safe and Effective Care Environment",
+      "subcategory": "Safety and Infection Control",
+      "cognitive_level": "analyze",
+      "clinical_judgment_stage": "Take Action",
+      "difficulty": "medium",
+      "tags": ["infection_control", "central_line", "crbsi", "sepsis", "chemotherapy", "telehealth"],
+      "source": "ASU CON Simulation Lab"
+    },
+    {
+      "question_id": "ASU-SAFE-003",
+      "stem": "A nurse is providing discharge education to a patient prescribed warfarin after a deep vein thrombosis. Which statement by the patient indicates a need for further teaching?",
+      "options": {
+        "A": "I should use an electric razor instead of a straight razor for shaving",
+        "B": "I need to have my blood tested regularly to check my INR levels",
+        "C": "I can take ibuprofen for headaches since it won't affect my warfarin",
+        "D": "I should report any unusual bruising or bleeding to my provider right away"
+      },
+      "correct_answer": "C",
+      "rationale": "NSAIDs such as ibuprofen increase the risk of bleeding when taken with warfarin due to their antiplatelet effects and potential to increase INR. This statement demonstrates a dangerous misunderstanding that requires immediate correction. Patients on warfarin should use acetaminophen for pain relief instead. The other statements reflect correct understanding of warfarin safety precautions: using an electric razor reduces laceration risk, regular INR monitoring is essential for dose adjustment, and reporting bleeding signs enables early intervention.",
+      "category": "Safe and Effective Care Environment",
+      "subcategory": "Safety and Infection Control",
+      "cognitive_level": "evaluate",
+      "clinical_judgment_stage": "Evaluate Outcomes",
+      "difficulty": "easy",
+      "tags": ["warfarin", "medication_safety", "patient_education", "anticoagulation", "drug_interaction", "discharge_education"],
+      "source": "ASU CON Simulation Lab"
+    },
+    {
+      "question_id": "ASU-HPM-001",
+      "stem": "A nurse is conducting a health promotion call with a 52-year-old patient with a family history of colon cancer. The patient states they have never had a colonoscopy and asks if it is really necessary. Which response best supports evidence-based health promotion?",
+      "options": {
+        "A": "It's your choice, but most people your age have already had one",
+        "B": "Current guidelines recommend colorectal screening beginning at age 45, and your family history may warrant earlier or more frequent screening",
+        "C": "You should schedule a colonoscopy as soon as possible because you are overdue",
+        "D": "There are stool-based tests available that are less invasive and just as effective"
+      },
+      "correct_answer": "B",
+      "rationale": "Evidence-based health promotion involves providing accurate, current guideline information tailored to the patient's individual risk factors. The USPSTF recommends colorectal cancer screening beginning at age 45 for average-risk adults, and first-degree family history of colon cancer is a significant risk factor that may necessitate earlier or more frequent screening per ACS guidelines. This response is informative, non-judgmental, and accounts for the patient's personal risk profile. Option A is dismissive, option C is directive without providing education, and option D is misleading (stool-based tests are not equivalent to colonoscopy for high-risk patients).",
+      "category": "Health Promotion and Maintenance",
+      "subcategory": "Health Promotion and Maintenance",
+      "cognitive_level": "apply",
+      "clinical_judgment_stage": "Generate Solutions",
+      "difficulty": "medium",
+      "tags": ["health_screening", "colorectal_cancer", "prevention", "patient_education", "family_history"],
+      "source": "ASU CON Simulation Lab"
+    },
+    {
+      "question_id": "ASU-HPM-002",
+      "stem": "A nurse is providing discharge education to a patient newly diagnosed with type 2 diabetes. The patient asks, 'Why do I need to check my feet every day when my problem is with my blood sugar?' Which explanation by the nurse is most accurate?",
+      "options": {
+        "A": "Checking your feet is part of the standard diabetes protocol that all patients must follow",
+        "B": "High blood sugar over time can damage nerves and blood vessels in your feet, making it harder to feel injuries that could lead to serious infections",
+        "C": "Your doctor ordered daily foot checks, so it is important to follow their instructions",
+        "D": "Diabetes causes your feet to swell, and daily checks help monitor for fluid retention"
+      },
+      "correct_answer": "B",
+      "rationale": "This response provides a pathophysiological explanation that directly answers the patient's question. Diabetic peripheral neuropathy results from chronic hyperglycemia damaging peripheral nerves, leading to decreased sensation (especially in the feet). Combined with peripheral vascular disease that impairs healing, undetected foot injuries can progress to ulceration, infection, and potentially amputation. Patient education should explain the 'why' behind self-care recommendations to promote understanding and adherence. Options A and C are authoritarian and fail to educate. Option D is inaccurate regarding the primary mechanism.",
+      "category": "Health Promotion and Maintenance",
+      "subcategory": "Health Promotion and Maintenance",
+      "cognitive_level": "apply",
+      "clinical_judgment_stage": "Generate Solutions",
+      "difficulty": "easy",
+      "tags": ["diabetes", "patient_education", "foot_care", "neuropathy", "self_management", "discharge_education"],
+      "source": "ASU CON Simulation Lab"
+    },
+    {
+      "question_id": "ASU-HPM-003",
+      "stem": "During a wellness call, a 68-year-old patient mentions they received their pneumococcal conjugate vaccine (PCV20) six months ago and asks if they need any additional pneumococcal vaccines. The patient has no history of immunocompromising conditions. Based on current CDC guidelines, what is the nurse's best response?",
+      "options": {
+        "A": "You will need PPSV23 one year after your PCV20 for complete protection",
+        "B": "You are up to date. PCV20 alone provides comprehensive coverage and no additional pneumococcal vaccines are needed",
+        "C": "You should receive PCV15 as a booster within the next 6 months",
+        "D": "Pneumococcal vaccines need to be repeated every 5 years like the tetanus booster"
+      },
+      "correct_answer": "B",
+      "rationale": "Per current CDC/ACIP guidelines, adults aged 65 and older who receive PCV20 (Prevnar 20) do not need any additional pneumococcal vaccines, as PCV20 covers all 20 serotypes including those in both PCV15 and PPSV23. The previous recommendation of PCV15 followed by PPSV23 was an alternative pathway, but PCV20 alone is sufficient. Pneumococcal vaccines are not repeated on a regular schedule like tetanus. This question tests the nurse's knowledge of current immunization guidelines, which is essential for accurate patient education during follow-up calls.",
+      "category": "Health Promotion and Maintenance",
+      "subcategory": "Health Promotion and Maintenance",
+      "cognitive_level": "remember",
+      "clinical_judgment_stage": "Recognize Cues",
+      "difficulty": "medium",
+      "tags": ["immunization", "pneumococcal", "elderly", "preventive_care", "cdc_guidelines", "patient_education"],
+      "source": "ASU CON Simulation Lab"
+    },
+    {
+      "question_id": "ASU-PSY-001",
+      "stem": "A nurse is making a follow-up call to a patient who was recently discharged after the death of their spouse. The patient says, 'I just don't see the point in taking my medications anymore. Nothing matters without them.' Which response demonstrates the most therapeutic communication?",
+      "options": {
+        "A": "I understand you're hurting. Your spouse would want you to take care of yourself",
+        "B": "You need to keep taking your medications. Stopping could make your condition worse",
+        "C": "It sounds like you're going through a very difficult time. Can you tell me more about how you've been feeling?",
+        "D": "I'm going to connect you with our grief counselor right away. They can help you through this"
+      },
+      "correct_answer": "C",
+      "rationale": "This response uses two key therapeutic communication techniques: reflection (acknowledging the emotional content of the patient's statement) and open-ended questioning (inviting the patient to elaborate). The patient's statement could indicate grief, depression, or even suicidal ideation, making further assessment essential before taking action. Option A makes assumptions about what the spouse would want (non-therapeutic). Option B dismisses the emotional content and focuses only on medication compliance. Option D jumps to an intervention without adequate assessment. The nurse must first explore whether the patient is expressing grief, hopelessness, or suicidal thoughts.",
+      "category": "Psychosocial Integrity",
+      "subcategory": "Psychosocial Integrity",
+      "cognitive_level": "analyze",
+      "clinical_judgment_stage": "Analyze Cues",
+      "difficulty": "medium",
+      "tags": ["therapeutic_communication", "grief", "mental_health", "medication_adherence", "assessment", "follow_up"],
+      "source": "ASU CON Simulation Lab"
+    },
+    {
+      "question_id": "ASU-PSY-002",
+      "stem": "During a post-discharge call, a patient recovering from a stroke says, 'I used to be so independent. Now I can't even button my own shirt. I'm just a burden to my family.' Which nursing response best addresses the patient's psychosocial needs?",
+      "options": {
+        "A": "Don't worry, many stroke patients make a full recovery with rehabilitation",
+        "B": "Your family loves you and doesn't think of you as a burden",
+        "C": "I can hear how frustrating this change has been for you. What activities are most important for you to regain?",
+        "D": "Have you considered hiring a home health aide to help with dressing and personal care?"
+      },
+      "correct_answer": "C",
+      "rationale": "This response validates the patient's feelings of loss and frustration while redirecting toward goal-setting and rehabilitation priorities. It demonstrates empathetic listening and a strengths-based approach by focusing on what the patient wants to achieve rather than dwelling on limitations. Option A offers false reassurance and minimizes the patient's experience. Option B dismisses the patient's feelings by speaking for the family. Option D jumps to a solution without exploring the patient's emotional needs or rehabilitation goals. Addressing the psychosocial impact of functional loss is essential for promoting engagement in rehabilitation.",
+      "category": "Psychosocial Integrity",
+      "subcategory": "Psychosocial Integrity",
+      "cognitive_level": "apply",
+      "clinical_judgment_stage": "Generate Solutions",
+      "difficulty": "medium",
+      "tags": ["stroke", "rehabilitation", "coping", "psychosocial", "therapeutic_communication", "follow_up"],
+      "source": "ASU CON Simulation Lab"
+    },
+    {
+      "question_id": "ASU-PHARM-001",
+      "stem": "A nurse is providing medication education during a post-discharge call to a patient prescribed metformin 500 mg twice daily for newly diagnosed type 2 diabetes. The patient asks when they should take the medication. What instruction is most appropriate?",
+      "options": {
+        "A": "Take it first thing in the morning on an empty stomach for best absorption",
+        "B": "Take it with your two largest meals of the day to reduce gastrointestinal side effects",
+        "C": "Take it at bedtime so the medication works while you sleep",
+        "D": "Take both doses together in the morning to simplify your medication routine"
+      },
+      "correct_answer": "B",
+      "rationale": "Metformin should be taken with meals to minimize the most common side effects: nausea, diarrhea, and abdominal discomfort. The twice-daily dosing with the two largest meals provides optimal absorption and GI tolerability. Taking it on an empty stomach (option A) significantly worsens GI side effects and is a leading cause of medication discontinuation. Bedtime administration (option C) is not the standard recommendation for immediate-release metformin. Combining both doses (option D) defeats the purpose of twice-daily dosing and increases side effect risk. Proper timing education is critical for medication adherence.",
+      "category": "Physiological Integrity",
+      "subcategory": "Pharmacological and Parenteral Therapies",
+      "cognitive_level": "apply",
+      "clinical_judgment_stage": "Take Action",
+      "difficulty": "easy",
+      "tags": ["metformin", "diabetes", "medication_education", "gi_side_effects", "patient_teaching", "discharge_education"],
+      "source": "ASU CON Simulation Lab"
+    },
+    {
+      "question_id": "ASU-PHARM-002",
+      "stem": "A patient calls the nurse line 3 days after discharge. They were prescribed lisinopril 10 mg daily for hypertension and report developing a persistent dry cough that started 2 days ago. Which nursing action is most appropriate?",
+      "options": {
+        "A": "Reassure the patient that the cough is temporary and will resolve within a week",
+        "B": "Instruct the patient to stop taking lisinopril immediately and await provider instructions",
+        "C": "Document the cough as a potential ACE inhibitor side effect and notify the prescribing provider for possible medication change",
+        "D": "Recommend an over-the-counter cough suppressant and advise the patient to continue the medication"
+      },
+      "correct_answer": "C",
+      "rationale": "A persistent dry cough is a well-known class effect of ACE inhibitors (including lisinopril), caused by accumulation of bradykinin in the lungs. It occurs in approximately 5-20% of patients and is the most common reason for ACE inhibitor discontinuation. The nurse should document this as a potential adverse drug reaction and notify the prescriber, who may switch to an ARB (angiotensin receptor blocker) which does not cause this side effect. The nurse should not independently stop a prescribed antihypertensive (option B) or dismiss the symptom (options A and D). An OTC cough suppressant will not resolve an ACE inhibitor-induced cough.",
+      "category": "Physiological Integrity",
+      "subcategory": "Pharmacological and Parenteral Therapies",
+      "cognitive_level": "analyze",
+      "clinical_judgment_stage": "Analyze Cues",
+      "difficulty": "medium",
+      "tags": ["ace_inhibitor", "lisinopril", "cough", "adverse_reaction", "hypertension", "nurse_line", "medication_side_effects"],
+      "source": "ASU CON Simulation Lab"
+    },
+    {
+      "question_id": "ASU-PHARM-003",
+      "stem": "During a medication reconciliation call, a nurse discovers that a patient is taking both prescribed warfarin and over-the-counter St. John's Wort for mild depression. The patient's last INR was 1.6 (therapeutic range 2.0-3.0). What should the nurse recognize about this interaction?",
+      "options": {
+        "A": "St. John's Wort potentiates warfarin and increases bleeding risk",
+        "B": "St. John's Wort induces hepatic enzymes that increase warfarin metabolism, reducing its therapeutic effect",
+        "C": "St. John's Wort has no clinically significant interaction with warfarin",
+        "D": "St. John's Wort competes with warfarin for protein binding sites, causing unpredictable effects"
+      },
+      "correct_answer": "B",
+      "rationale": "St. John's Wort is a potent inducer of CYP3A4 and CYP2C9 hepatic enzymes, which are the primary metabolic pathways for warfarin. This enzyme induction accelerates warfarin metabolism, leading to subtherapeutic INR levels and increased risk of thromboembolic events. The patient's INR of 1.6 (below the therapeutic range of 2.0-3.0) is consistent with this drug-herb interaction. This is a clinically significant and well-documented interaction. The nurse should report this finding to the prescriber immediately. This question highlights the importance of comprehensive medication reconciliation including OTC supplements and herbal products.",
+      "category": "Physiological Integrity",
+      "subcategory": "Pharmacological and Parenteral Therapies",
+      "cognitive_level": "analyze",
+      "clinical_judgment_stage": "Analyze Cues",
+      "difficulty": "hard",
+      "tags": ["warfarin", "drug_interaction", "st_johns_wort", "medication_reconciliation", "inr", "herbal_supplement"],
+      "source": "ASU CON Simulation Lab"
+    },
+    {
+      "question_id": "ASU-BASIC-001",
+      "stem": "A nurse is conducting a post-discharge call with a patient who had abdominal surgery 4 days ago. The patient reports having no bowel movement since surgery and complains of bloating and discomfort. Which dietary recommendation is most appropriate?",
+      "options": {
+        "A": "Increase intake of dairy products such as cheese and yogurt to promote gut flora",
+        "B": "Encourage clear liquids only until bowel function returns",
+        "C": "Recommend increasing fiber-rich foods gradually, adequate fluid intake, and gentle ambulation",
+        "D": "Suggest a protein-rich diet with red meat to promote surgical wound healing"
+      },
+      "correct_answer": "C",
+      "rationale": "Post-surgical ileus and constipation are common after abdominal surgery due to anesthesia effects, opioid analgesic use, decreased mobility, and surgical manipulation of the bowel. A gradual increase in dietary fiber (fruits, vegetables, whole grains), adequate hydration (at least 8 glasses of water daily), and early ambulation are first-line non-pharmacological interventions that promote return of bowel motility. Dairy products (option A) can worsen constipation. Clear liquids only (option B) provide inadequate fiber and calories. High-protein/red meat diets (option D) without fiber can worsen constipation. The key word is 'gradually' since too rapid an increase in fiber can cause additional bloating.",
+      "category": "Physiological Integrity",
+      "subcategory": "Basic Care and Comfort",
+      "cognitive_level": "apply",
+      "clinical_judgment_stage": "Generate Solutions",
+      "difficulty": "easy",
+      "tags": ["post_surgical", "constipation", "nutrition", "bowel_function", "patient_education", "discharge"],
+      "source": "ASU CON Simulation Lab"
+    },
+    {
+      "question_id": "ASU-BASIC-002",
+      "stem": "A patient recovering from a total hip replacement calls the nurse line reporting pain rated 7/10 in the surgical hip. The patient states they have been taking their prescribed acetaminophen 650 mg every 6 hours but it is not providing adequate relief. The patient also reports they have been lying in bed most of the day to avoid pain. What is the nurse's best response?",
+      "options": {
+        "A": "Continue the current pain regimen and try applying ice to the hip for 20 minutes every 2 hours",
+        "B": "Assess the patient's pain characteristics in detail, encourage prescribed mobility exercises, and contact the provider about inadequate pain control",
+        "C": "Recommend the patient add ibuprofen 400 mg to their current regimen for better pain control",
+        "D": "Advise the patient to rest in bed until the pain decreases to a manageable level"
+      },
+      "correct_answer": "B",
+      "rationale": "A comprehensive nursing response addresses multiple concerns: (1) Further pain assessment is needed to rule out complications such as dislocation, infection, or DVT. (2) Immobility after total hip replacement increases the risk of DVT, pneumonia, and actually worsens stiffness and pain long-term. Prescribed mobility exercises are essential for recovery. (3) Uncontrolled pain (7/10) despite scheduled acetaminophen warrants provider notification for possible medication adjustment. The nurse should not independently recommend adding NSAIDs (option C) without provider order, as some post-surgical patients have contraindications. Bed rest (option D) is contraindicated. Ice alone (option A) is insufficient for 7/10 pain.",
+      "category": "Physiological Integrity",
+      "subcategory": "Basic Care and Comfort",
+      "cognitive_level": "analyze",
+      "clinical_judgment_stage": "Take Action",
+      "difficulty": "medium",
+      "tags": ["pain_management", "hip_replacement", "mobility", "post_surgical", "nurse_line", "dvt_prevention"],
+      "source": "ASU CON Simulation Lab"
+    },
+    {
+      "question_id": "ASU-BASIC-003",
+      "stem": "During a care transition call, a patient with COPD who uses home oxygen at 2 L/min via nasal cannula asks if they can increase the flow rate to 4 L/min when they feel more short of breath during activity. What should the nurse teach the patient?",
+      "options": {
+        "A": "Yes, increasing to 4 L/min during activity is a safe and common practice for COPD patients",
+        "B": "No, never change your oxygen flow rate. Call 911 if you feel short of breath",
+        "C": "Do not adjust your oxygen without provider guidance. In some COPD patients, too much oxygen can suppress the drive to breathe. Contact your provider to discuss an activity oxygen prescription",
+        "D": "You can safely increase to 3 L/min but should not exceed that amount"
+      },
+      "correct_answer": "C",
+      "rationale": "Some patients with chronic COPD develop a hypoxic respiratory drive, meaning their stimulus to breathe is triggered by low oxygen levels rather than high CO2 levels. Excessive supplemental oxygen can blunt this drive, leading to hypoventilation, CO2 retention, and respiratory failure. Patients should not independently adjust their prescribed oxygen flow rate. However, the nurse should not be alarmist (option B) or give permission without provider input (options A and D). The appropriate action is to educate the patient about the risk and facilitate a provider consultation about activity-level oxygen needs, which may indeed warrant a higher prescribed rate for exertion.",
+      "category": "Physiological Integrity",
+      "subcategory": "Basic Care and Comfort",
+      "cognitive_level": "apply",
+      "clinical_judgment_stage": "Generate Solutions",
+      "difficulty": "medium",
+      "tags": ["copd", "oxygen_therapy", "patient_education", "respiratory", "care_transition", "home_health"],
+      "source": "ASU CON Simulation Lab"
+    },
+    {
+      "question_id": "ASU-RISK-001",
+      "stem": "A nurse is reviewing lab results during a post-discharge follow-up call for a patient on digoxin and furosemide. The results show: potassium 3.1 mEq/L (normal 3.5-5.0), digoxin level 1.8 ng/mL (therapeutic 0.8-2.0), creatinine 1.8 mg/dL (normal 0.7-1.3). Which finding requires the most urgent action?",
+      "options": {
+        "A": "The elevated creatinine indicating possible renal impairment",
+        "B": "The digoxin level approaching the upper limit of the therapeutic range",
+        "C": "The hypokalemia, which increases the risk of digoxin toxicity",
+        "D": "All three findings are within acceptable ranges and require routine monitoring only"
+      },
+      "correct_answer": "C",
+      "rationale": "Hypokalemia (K+ 3.1 mEq/L) in a patient taking digoxin is the most urgent finding because low potassium levels potentiate the effects of digoxin, significantly increasing the risk of digoxin toxicity and potentially fatal cardiac dysrhythmias. The mechanism involves competitive binding: potassium and digoxin compete for the same binding site on the Na+/K+ ATPase pump. When potassium is low, more digoxin binds, intensifying its effect. The digoxin level is technically within range but combined with hypokalemia effectively acts as a supratherapeutic level. Furosemide (a loop diuretic) is the likely cause of the potassium loss. The elevated creatinine is concerning and may further impair digoxin clearance, but the hypokalemia poses the most immediate risk.",
+      "category": "Physiological Integrity",
+      "subcategory": "Reduction of Risk Potential",
+      "cognitive_level": "analyze",
+      "clinical_judgment_stage": "Prioritize Hypotheses",
+      "difficulty": "hard",
+      "tags": ["lab_values", "digoxin", "hypokalemia", "drug_interaction", "furosemide", "cardiac", "renal_function"],
+      "source": "ASU CON Simulation Lab"
+    },
+    {
+      "question_id": "ASU-RISK-002",
+      "stem": "During a post-discharge assessment call on day 2 following a cesarean section, the patient reports sudden onset of unilateral calf pain, swelling, and warmth in her left leg. She mentions she has been mostly resting in bed since coming home. What is the nurse's priority action?",
+      "options": {
+        "A": "Advise the patient to elevate the leg and apply warm compresses to relieve the discomfort",
+        "B": "Instruct the patient to massage the affected calf to improve circulation",
+        "C": "Direct the patient to seek immediate medical evaluation for suspected deep vein thrombosis",
+        "D": "Recommend the patient begin walking to improve venous return and reassess in 24 hours"
+      },
+      "correct_answer": "C",
+      "rationale": "The clinical presentation (unilateral calf pain, swelling, warmth, recent surgery, postpartum state, immobility) is highly consistent with deep vein thrombosis (DVT). Post-cesarean patients have multiple Virchow's triad risk factors: venous stasis from immobility, endothelial injury from surgery, and hypercoagulability of pregnancy/postpartum state. DVT requires urgent medical evaluation including diagnostic ultrasound and potential anticoagulation therapy. Massaging the affected extremity (option B) is strictly contraindicated as it could dislodge a clot, causing a potentially fatal pulmonary embolism. Delayed assessment (option D) risks PE progression. Warm compresses alone (option A) fail to address the urgency of the situation.",
+      "category": "Physiological Integrity",
+      "subcategory": "Reduction of Risk Potential",
+      "cognitive_level": "analyze",
+      "clinical_judgment_stage": "Take Action",
+      "difficulty": "medium",
+      "tags": ["dvt", "postpartum", "cesarean_section", "venous_thromboembolism", "assessment", "post_discharge", "emergency"],
+      "source": "ASU CON Simulation Lab"
+    },
+    {
+      "question_id": "ASU-ADAPT-001",
+      "stem": "A nurse receives a call from a patient discharged yesterday after treatment for diabetic ketoacidosis (DKA). The patient reports excessive thirst, frequent urination, blood glucose reading of 420 mg/dL, nausea, and fruity-smelling breath. Which action should the nurse take first?",
+      "options": {
+        "A": "Instruct the patient to administer their prescribed sliding-scale insulin and recheck in 1 hour",
+        "B": "Advise the patient to drink plenty of water to prevent dehydration and call back in 2 hours",
+        "C": "Direct the patient to go to the emergency department immediately as these are signs of recurrent DKA",
+        "D": "Tell the patient to take their oral diabetes medication and avoid eating until blood sugar normalizes"
+      },
+      "correct_answer": "C",
+      "rationale": "The patient is presenting with classic signs and symptoms of recurrent diabetic ketoacidosis: severe hyperglycemia (420 mg/dL), polydipsia, polyuria, nausea, and fruity breath (indicating ketone production). DKA is a life-threatening emergency requiring IV fluid resuscitation, continuous insulin infusion, and electrolyte monitoring in an acute care setting. Home management with sliding-scale insulin (option A) is insufficient for DKA. Fluid intake alone (option B) cannot correct the metabolic acidosis and insulin deficiency. Oral medications (option D) are ineffective in DKA and the patient is nauseated. Having just been hospitalized for DKA, this recurrence suggests the patient's diabetes management plan needs urgent reassessment.",
+      "category": "Physiological Integrity",
+      "subcategory": "Physiological Adaptation",
+      "cognitive_level": "apply",
+      "clinical_judgment_stage": "Take Action",
+      "difficulty": "medium",
+      "tags": ["dka", "diabetes", "emergency", "hyperglycemia", "metabolic_acidosis", "post_discharge", "readmission"],
+      "source": "ASU CON Simulation Lab"
+    }
+  ]
+}
diff --git a/list/tenants/asu/team_email_nclex_baseline.txt b/list/tenants/asu/team_email_nclex_baseline.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c454ef677245fea6fb727722d0ed9ee82aff6335
--- /dev/null
+++ b/list/tenants/asu/team_email_nclex_baseline.txt
@@ -0,0 +1,56 @@
+Subject: ASU Stage Gate 1 -- NCLEX Knowledge Test Framework Built + Baseline Results
+
+Team,
+
+Quick update on the ASU College of Nursing engagement. I've built the testing framework for Stage Gate 1 (Knowledge Assessment) and ran our first baseline.
+
+What We Built
+
+The SOW defines a three-part assessment model: Knowledge (NCLEX-style MCQ), Clinical Reasoning (case simulations), and Human Interaction (empathy/safety scoring). The first stage gate is the knowledge test, so that's what we've scaffolded.
+
+We now have a complete NCLEX evaluation harness that can:
+- Load question banks in any size (JSON format matching the NCLEX-RN 2023 test plan structure)
+- Run them through Avery (Claude) and score automatically
+- Break down results by all NCLEX dimensions: Client Needs categories, subcategories, cognitive levels, clinical judgment stages, and difficulty
+- Generate reports in Markdown and JSON
+- Compare runs over time to track improvement
+
+The question bank structure follows the official NCLEX-RN 2023 test plan with all 4 Client Needs categories, 8 subcategories, 6 Clinical Judgment Model stages, and Bloom's taxonomy cognitive levels. Questions are weighted according to the published NCSBN percentage ranges so we can validate that our question distribution matches the real exam.
+
+Sample Bank and Baseline Results
+
+I wrote a 21-question sample bank covering all 8 NCLEX subcategories. The questions are scenario-based and aligned with the ASU SOW Phase I scope: patient education, care transitions, discharge planning, medication education, and telephonic nursing contexts.
+
+Baseline results with Avery (Claude):
+
+  Overall: 21/21 (100%) -- PASS
+  Passing threshold: 65% (approximating NCLEX-RN standard)
+  Mean confidence: 93.7%
+
+  By Category:
+  - Safe and Effective Care Environment: 7/7 (100%)
+  - Health Promotion and Maintenance: 3/3 (100%)
+  - Psychosocial Integrity: 2/2 (100%)
+  - Physiological Integrity: 9/9 (100%)
+
+  By Difficulty:
+  - Easy: 5/5 (100%)
+  - Medium: 13/13 (100%)
+  - Hard: 3/3 (100%)
+
+The 100% score on a 21-question sample bank is a strong starting point but expected -- these are well-structured MCQs where the correct answer is clinically unambiguous. The real test will come when ASU provides their question banks, which will likely include more nuanced items with closer distractors and potentially questions that test the boundaries of Avery's clinical reasoning.
+
+What's Next
+
+1. ASU provides their NCLEX question banks (we can ingest any size bank in our JSON format)
+2. We run Avery against their questions and share results
+3. Based on the score breakdowns, we identify any subcategory weaknesses and address them
+4. Once we clear the knowledge gate, we move to Stage Gate 2 (Clinical Reasoning with case simulations)
+
+The testing infrastructure is fully automated -- we can re-run against updated question banks at any time and compare results across runs.
+
+Everything is committed and lives under config/tenants/asu/ alongside the existing USF sim lab tenant.
+
+Let me know if you have questions.
+
+Matt
diff --git a/list/tenants/asu/tenant.yaml b/list/tenants/asu/tenant.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..4d6ac47b4013cdd45b083445b85e6c339dac30b7
--- /dev/null
+++ b/list/tenants/asu/tenant.yaml
@@ -0,0 +1,44 @@
+tenant_id: asu
+tenant_name: "Arizona State University"
+
+enabled_wedges:
+  - sim_education
+
+enabled_journeys:
+  - sim_lab_education
+
+custom_escalation_rules: []
+
+institution_context:
+  name: "Arizona State University"
+  type: academic_medical_center
+  nurse_line_number: "TBD"
+  ed_name: "TBD"
+  ehr_system: other
+  timezone: "America/Phoenix"
+
+data_source_config:
+  auth_method: api_key
+
+branding:
+  institution_name: "Arizona State University"
+  caller_introduction: "Hi, this is Avery calling from Arizona State University."
+  nurse_line_label: "the ASU health services line"
+  emergency_instructions: "call 911 or go to the nearest emergency department"
+
+domain_overrides:
+  acute_confusion:
+    enabled: false
+  copd_exacerbation:
+    enabled: false
+  severe_bleeding:
+    enabled: false
+  gi_bleed:
+    enabled: false
+  anticoagulation_monitoring:
+    enabled: false
+
+compliance_settings:
+  audit_retention_days: 2555
+  phi_logging_enabled: false
+  require_consent_recording: false
diff --git a/list/tenants/example_academic_mc/tenant.yaml b/list/tenants/example_academic_mc/tenant.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..ef7c25741eb440d289c9385bbe52537f9ecfeb0f
--- /dev/null
+++ b/list/tenants/example_academic_mc/tenant.yaml
@@ -0,0 +1,75 @@
+tenant_id: example_academic_mc
+tenant_name: "University Medical Center"
+
+enabled_wedges:
+  - pde
+  - pre_op
+  - awv
+
+enabled_journeys:
+  - post_discharge_engagement
+  - pre_op_optimization
+  - annual_wellness_visit
+
+custom_escalation_rules:
+  - rule_id: academic_chest_pain_postsurg
+    mode: add
+    domain: chest_pain
+    description: "Post-surgical patients with chest pain always escalate to R3"
+    conditions:
+      slots_present:
+        - chest_pain_onset
+    target_risk_class: R3
+
+institution_context:
+  name: "University Medical Center"
+  type: academic_medical_center
+  nurse_line_number: "1-800-555-0100"
+  ed_name: "UMC Emergency Department"
+  formulary_url: "https://formulary.umc.example.edu"
+  ehr_system: epic
+  timezone: "America/New_York"
+  operating_hours:
+    default:
+      start_hour: 8
+      end_hour: 20
+    saturday:
+      start_hour: 9
+      end_hour: 17
+  custom_protocols:
+    - "UMC-CP-001 Post-Cardiac Surgery Monitoring"
+    - "UMC-CP-002 Transplant Follow-Up"
+
+data_source_config:
+  fhir_base_url: "https://fhir.umc.example.edu/api/FHIR/R4"
+  auth_method: smart_backend
+  client_id: "umc-dce-client-001"
+  key_file: "/etc/dce/keys/umc_private.pem"
+  resource_scopes:
+    - "Patient.read"
+    - "Condition.read"
+    - "MedicationRequest.read"
+    - "Observation.read"
+    - "AllergyIntolerance.read"
+    - "Appointment.read"
+    - "ServiceRequest.read"
+
+branding:
+  institution_name: "University Medical Center"
+  caller_introduction: "Hi, this is Avery calling from University Medical Center."
+  nurse_line_label: "our 24-hour nurse advice line at 1-800-555-0100"
+  emergency_instructions: "go to the UMC Emergency Department or call 911"
+
+compliance_settings:
+  audit_retention_days: 2555
+  phi_logging_enabled: false
+  require_consent_recording: true
+  hipaa_baa_reference: "BAA-UMC-2024-001"
+
+escalation_review:
+  r3_mode: concurrent_transfer
+  r2_mode: hcp_review_first
+  r1_mode: pass_through
+  r3_nurse_sla_seconds: 10
+  r2_nurse_sla_seconds: 90
+  timeout_action: general_safety
diff --git a/list/tenants/example_community_hospital/tenant.yaml b/list/tenants/example_community_hospital/tenant.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..3327620780a13c2eeaf0c8974775a693e182948e
--- /dev/null
+++ b/list/tenants/example_community_hospital/tenant.yaml
@@ -0,0 +1,56 @@
+tenant_id: example_community_hospital
+tenant_name: "Riverside Community Hospital"
+
+enabled_wedges:
+  - pde
+
+enabled_journeys:
+  - post_discharge_engagement
+
+custom_escalation_rules: []
+
+institution_context:
+  name: "Riverside Community Hospital"
+  type: community_hospital
+  nurse_line_number: "1-800-555-0200"
+  ed_name: "Riverside Emergency Room"
+  ehr_system: oracle_health
+  timezone: "America/Chicago"
+  operating_hours:
+    default:
+      start_hour: 8
+      end_hour: 18
+
+data_source_config:
+  fhir_base_url: "https://fhir.riverside.example.org/api/FHIR/R4"
+  auth_method: oauth2
+  client_id: "riverside-dce-client"
+  resource_scopes:
+    - "Patient.read"
+    - "Condition.read"
+    - "MedicationRequest.read"
+    - "Observation.read"
+  fallback_source: mock
+
+branding:
+  institution_name: "Riverside Community Hospital"
+  caller_introduction: "Hi, this is Avery calling from Riverside Community Hospital."
+  nurse_line_label: "our nurse line at 1-800-555-0200"
+  emergency_instructions: "go to the Riverside Emergency Room or call 911"
+
+domain_overrides:
+  post_procedure_incontinence:
+    enabled: false
+
+compliance_settings:
+  audit_retention_days: 2555
+  phi_logging_enabled: false
+  require_consent_recording: true
+
+escalation_review:
+  r3_mode: concurrent_transfer
+  r2_mode: hcp_review_first
+  r1_mode: pass_through
+  r3_nurse_sla_seconds: 15
+  r2_nurse_sla_seconds: 120
+  timeout_action: general_safety
diff --git a/list/tenants/example_crisis_center/tenant.yaml b/list/tenants/example_crisis_center/tenant.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..12e7e48c31f5f2caa11f69422713fcb7831ab060
--- /dev/null
+++ b/list/tenants/example_crisis_center/tenant.yaml
@@ -0,0 +1,52 @@
+tenant_id: example_crisis_center
+tenant_name: "Behavioral Health Crisis Center"
+
+enabled_wedges:
+  - crisis_line
+
+enabled_journeys:
+  - mhbh_crisis_line
+
+custom_escalation_rules: []
+
+institution_context:
+  name: "Behavioral Health Crisis Center"
+  type: community_hospital
+  nurse_line_number: "988"
+  ed_name: "Crisis Stabilization Unit"
+  ehr_system: epic
+  timezone: "America/Chicago"
+  operating_hours:
+    default:
+      start_hour: 0
+      end_hour: 24
+
+data_source_config:
+  fhir_base_url: "https://fhir.bhcc.example.org/api/FHIR/R4"
+  auth_method: smart_backend
+  client_id: "bhcc-dce-client-001"
+  key_file: "/etc/dce/keys/bhcc_private.pem"
+  resource_scopes:
+    - "Patient.read"
+    - "Condition.read"
+    - "MedicationRequest.read"
+
+branding:
+  institution_name: "Behavioral Health Crisis Center"
+  caller_introduction: "Hi, this is Avery with the Behavioral Health Crisis Center. I'm here to help."
+  nurse_line_label: "the 988 Suicide and Crisis Lifeline"
+  emergency_instructions: "call 988 or 911 if you are in immediate danger"
+
+compliance_settings:
+  audit_retention_days: 2555
+  phi_logging_enabled: false
+  require_consent_recording: true
+  hipaa_baa_reference: "BAA-BHCC-2024-001"
+
+escalation_review:
+  r3_mode: concurrent_transfer
+  r2_mode: hcp_review_first
+  r1_mode: pass_through
+  r3_nurse_sla_seconds: 10
+  r2_nurse_sla_seconds: 60
+  timeout_action: general_safety
diff --git a/list/tenants/example_health_system/tenant.yaml b/list/tenants/example_health_system/tenant.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..418d3e1768b869fa2ce37be77774efbc7e47a762
--- /dev/null
+++ b/list/tenants/example_health_system/tenant.yaml
@@ -0,0 +1,92 @@
+tenant_id: example_health_system
+tenant_name: "Mercy Health System"
+
+enabled_wedges:
+  - pde
+  - pre_op
+  - awv
+  - gap_closure
+  - hra
+
+enabled_journeys:
+  - post_discharge_engagement
+  - pre_op_optimization
+  - annual_wellness_visit
+  - gap_closure
+  - health_risk_assessment
+
+custom_escalation_rules:
+  - rule_id: mercy_fall_elderly
+    mode: add
+    domain: fall_high_risk
+    description: "Patients 75+ with any fall report escalate to R2 regardless of injury"
+    conditions:
+      slots_present:
+        - fall_reported
+      slot_values:
+        fall_reported: "yes"
+    target_risk_class: R2
+  - rule_id: mercy_hf_weight_gain
+    mode: add
+    domain: heart_failure_worsening
+    description: "Any weight gain in CHF patients triggers R2 for same-day callback"
+    conditions:
+      slots_present:
+        - weight_change_reported
+    target_risk_class: R2
+
+institution_context:
+  name: "Mercy Health System"
+  type: health_system
+  nurse_line_number: "1-800-555-0300"
+  ed_name: "Mercy Emergency Department"
+  formulary_url: "https://formulary.mercy.example.com"
+  ehr_system: epic
+  timezone: "America/Chicago"
+  operating_hours:
+    default:
+      start_hour: 7
+      end_hour: 21
+    sunday:
+      start_hour: 9
+      end_hour: 17
+  custom_protocols:
+    - "MERCY-001 CHF Readmission Prevention"
+    - "MERCY-002 Opioid Safety Monitoring"
+    - "MERCY-003 Sepsis Screening Protocol"
+
+data_source_config:
+  fhir_base_url: "https://fhir.mercy.example.com/api/FHIR/R4"
+  auth_method: smart_backend
+  client_id: "mercy-dce-client-prod"
+  key_file: "/etc/dce/keys/mercy_private.pem"
+  resource_scopes:
+    - "Patient.read"
+    - "Condition.read"
+    - "MedicationRequest.read"
+    - "Observation.read"
+    - "AllergyIntolerance.read"
+    - "Immunization.read"
+    - "Appointment.read"
+    - "ServiceRequest.read"
+    - "DocumentReference.read"
+
+branding:
+  institution_name: "Mercy Health"
+  caller_introduction: "Hi, this is Avery calling from Mercy Health."
+  nurse_line_label: "our 24-hour Mercy nurse line at 1-800-555-0300"
+  emergency_instructions: "go to the nearest Mercy Emergency Department or call 911"
+
+compliance_settings:
+  audit_retention_days: 2920
+  phi_logging_enabled: false
+  require_consent_recording: true
+  hipaa_baa_reference: "BAA-MERCY-2024-001"
+
+escalation_review:
+  r3_mode: concurrent_transfer
+  r2_mode: hcp_review_first
+  r1_mode: pass_through
+  r3_nurse_sla_seconds: 15
+  r2_nurse_sla_seconds: 120
+  timeout_action: general_safety
diff --git a/list/tenants/usf_sim_lab/pilot_documents/DH_USF_Pilot_ScopingDoc_120525 (1).docx b/list/tenants/usf_sim_lab/pilot_documents/DH_USF_Pilot_ScopingDoc_120525 (1).docx
new file mode 100644
index 0000000000000000000000000000000000000000..5ee8e79d05c93d4b079dafb2cc3df1301ffc58ef
--- /dev/null
+++ b/list/tenants/usf_sim_lab/pilot_documents/DH_USF_Pilot_ScopingDoc_120525 (1).docx	
@@ -0,0 +1,3 @@
+version https://git-lfs.github.com/spec/v1
+oid sha256:585804443ceed99084272677bd83e3bc4019cb0ae35e46dd6bb9f0020263c7a2
+size 1225802
diff --git a/list/tenants/usf_sim_lab/pilot_documents/Drive x USF - SimLab Pilot Scope.xlsx b/list/tenants/usf_sim_lab/pilot_documents/Drive x USF - SimLab Pilot Scope.xlsx
new file mode 100644
index 0000000000000000000000000000000000000000..518aff4479f3c07ae2b39f98daa809991dec2117
--- /dev/null
+++ b/list/tenants/usf_sim_lab/pilot_documents/Drive x USF - SimLab Pilot Scope.xlsx	
@@ -0,0 +1,3 @@
+version https://git-lfs.github.com/spec/v1
+oid sha256:bcc380def2cbfd33fff8ea4f11e1c72fa17dd0fe073ff97dc67c48430b021c57
+size 57321
diff --git a/list/tenants/usf_sim_lab/pilot_documents/Scoping_Planning_02-18-2026 (1).docx b/list/tenants/usf_sim_lab/pilot_documents/Scoping_Planning_02-18-2026 (1).docx
new file mode 100644
index 0000000000000000000000000000000000000000..1aab71173c1efacb00f64d149a4de183ca3e9a18
--- /dev/null
+++ b/list/tenants/usf_sim_lab/pilot_documents/Scoping_Planning_02-18-2026 (1).docx	
@@ -0,0 +1,3 @@
+version https://git-lfs.github.com/spec/v1
+oid sha256:f0053a7cf04044d6ebc5a2130e6c9a150f6406d268aaf73096f746abf569be75
+size 10489
diff --git a/list/tenants/usf_sim_lab/pilot_documents/recent_update.txt b/list/tenants/usf_sim_lab/pilot_documents/recent_update.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c00a329695b97b879d4d77642216a0ce2d55247b
--- /dev/null
+++ b/list/tenants/usf_sim_lab/pilot_documents/recent_update.txt
@@ -0,0 +1,18 @@
+Just to update you and also ask some questions. Helen and I met earlier this week to discuss some of the specific pt education that Avery can do.
+Bob Barker:  COPD management and importance of not smoking and use of Nicotine Patch. We thought we would make him a little drowsy and/or a little confused
+Sean White: since he has a DVT, we could education on DVT and anticoagulation therapy and bleeding precautions
+
+Based on those two decisions, we decided that
+Janice: would create the SOAP note 
+I am going to create a quick Pre-work learning module for students to review how to write a SOAP note. They learned this a couple of semesters ago, but not sure how many students actually use SOAP notes and/or remember how to write one
+Question:  I can write the model SOAP note to use as a basis for the SOAP Note rubric, BUT, it is difficulty for me to do this until I get the script from your team.
+Janice:  TA and SIM Faculty Notification
+I will send an email and schedule an informational meeting for the SIM TAs and SIM instructors to explain the pilot and explain their roles
+Question:  Are you or any of your team interested in attending this informational meeting?
+Helen: Will create the grading rubric
+Question:  I am guessing that we will need a rubric for the SOAP note and one for the Pt-Education simulation session for Avery? Please confirm
+Question:  I am guessing that we will need the SIM instructors to assist with grading the SOAP notes and use the rubric for grading?
+
+Thanks,
+Janice
+
diff --git a/list/tenants/usf_sim_lab/refs/GOLD-REPORT-2026-v1.3-8Dec2025_WMV2.pdf b/list/tenants/usf_sim_lab/refs/GOLD-REPORT-2026-v1.3-8Dec2025_WMV2.pdf
new file mode 100644
index 0000000000000000000000000000000000000000..02bc61f18a2155492f9880160cda91a9fd19513a
--- /dev/null
+++ b/list/tenants/usf_sim_lab/refs/GOLD-REPORT-2026-v1.3-8Dec2025_WMV2.pdf
@@ -0,0 +1,3 @@
+version https://git-lfs.github.com/spec/v1
+oid sha256:fa12e8e2dbd2090ea84d1a05ba48ab6d967fb1ce9a54d987e54249475714ddac
+size 20005544
diff --git a/list/tenants/usf_sim_lab/refs/VTE_Lancet.pdf b/list/tenants/usf_sim_lab/refs/VTE_Lancet.pdf
new file mode 100644
index 0000000000000000000000000000000000000000..a0ddd51f1c088efe66943e7454b28d090aa48b18
--- /dev/null
+++ b/list/tenants/usf_sim_lab/refs/VTE_Lancet.pdf
@@ -0,0 +1,3 @@
+version https://git-lfs.github.com/spec/v1
+oid sha256:30b607501085ecd530c16a03f1891d2057130d08971694f2240e70ee26ac9e70
+size 737989
diff --git a/list/tenants/usf_sim_lab/scenarios/bob_barker_anxious.json b/list/tenants/usf_sim_lab/scenarios/bob_barker_anxious.json
new file mode 100644
index 0000000000000000000000000000000000000000..bc7c1ce6580f85a7aea08b1a9e80fa7c98c651db
--- /dev/null
+++ b/list/tenants/usf_sim_lab/scenarios/bob_barker_anxious.json
@@ -0,0 +1,132 @@
+{
+  "scenario_id": "bob_barker_anxious",
+  "patient_name": "Bob Barker",
+  "patient_dob": "1958-03-15",
+  "education_domain": "copd_education",
+  "archetype": "anxious",
+  "agenda_sequence": [
+    "edu_intro",
+    "diagnosis_understanding",
+    "smoking_cessation",
+    "nicotine_patch_use",
+    "summary_note"
+  ],
+  "patient_context": {
+    "age": 68,
+    "sex": "male",
+    "active_conditions": [
+      {
+        "code": "J44.1",
+        "display": "Chronic obstructive pulmonary disease with acute exacerbation",
+        "system": "ICD-10-CM",
+        "status": "active",
+        "category": "encounter-diagnosis"
+      },
+      {
+        "code": "F17.210",
+        "display": "Nicotine dependence, cigarettes, uncomplicated",
+        "system": "ICD-10-CM",
+        "status": "active",
+        "category": "problem-list-item"
+      },
+      {
+        "code": "I10",
+        "display": "Essential (primary) hypertension",
+        "system": "ICD-10-CM",
+        "status": "active",
+        "category": "problem-list-item"
+      }
+    ],
+    "active_medications": [
+      {
+        "name": "Nicotine Patch",
+        "dose": "21mg/24hr",
+        "frequency": "daily",
+        "route": "topical",
+        "is_high_risk": false,
+        "instructions": "Step-down schedule: 21mg x 4 weeks, then 14mg x 2 weeks, then 7mg x 2 weeks. 8-week course total."
+      },
+      {
+        "name": "Albuterol MDI (SABA)",
+        "dose": "90mcg/puff, 2 puffs",
+        "frequency": "PRN",
+        "route": "inhaled",
+        "is_high_risk": false,
+        "instructions": "Use as needed for shortness of breath. Shake well before each use."
+      },
+      {
+        "name": "Tiotropium (Spiriva) (LAMA)",
+        "dose": "18mcg",
+        "frequency": "daily",
+        "route": "inhaled",
+        "is_high_risk": false,
+        "instructions": "Use once daily for long-term airway maintenance."
+      }
+    ],
+    "clinical_summary": {
+      "smoking_history": "40 pack-year history (1 pack/day x 40 years). Current smoker at admission.",
+      "spirometry": "FEV1 52% predicted (GOLD Grade 2 - moderate airflow obstruction). FEV1/FVC 0.58 post-bronchodilator.",
+      "gold_classification": "GOLD Grade 2, Group E (moderate obstruction with recent exacerbation)",
+      "vital_signs_at_discharge": {
+        "heart_rate": 82,
+        "respiratory_rate": 20,
+        "blood_pressure": "138/84",
+        "oxygen_saturation": 93,
+        "temperature": 98.2
+      }
+    },
+    "discharge_info": {
+      "diagnosis_code": "J44.1",
+      "diagnosis_display": "COPD with acute exacerbation",
+      "discharge_date": "2026-02-27T10:00:00",
+      "discharge_medications": [
+        {
+          "name": "Nicotine Patch",
+          "dose": "21mg/24hr",
+          "frequency": "daily",
+          "route": "topical",
+          "is_high_risk": false
+        },
+        {
+          "name": "Albuterol MDI (SABA)",
+          "dose": "90mcg/puff, 2 puffs",
+          "frequency": "PRN",
+          "route": "inhaled",
+          "is_high_risk": false
+        },
+        {
+          "name": "Tiotropium (Spiriva) (LAMA)",
+          "dose": "18mcg",
+          "frequency": "daily",
+          "route": "inhaled",
+          "is_high_risk": false
+        }
+      ],
+      "discharge_instructions": "Apply nicotine patch daily, rotate site. Avoid smoking. Use rescue inhaler (albuterol) as needed for shortness of breath. Continue tiotropium daily. Follow up with pulmonology in 1 week.",
+      "length_of_stay_days": 3,
+      "discharge_disposition": "home"
+    },
+    "upcoming_appointments": [
+      {
+        "type": "follow_up",
+        "provider": "Dr. Patel, Pulmonology",
+        "date": "2026-03-06T14:00:00",
+        "location": "USF Health Pulmonology Clinic",
+        "status": "scheduled",
+        "visit_reason": "Post-discharge COPD follow-up"
+      }
+    ],
+    "known_barriers": [
+      {
+        "type": "anxiety",
+        "description": "Patient is highly anxious and distrustful of the healthcare system. Validate feelings, do not rush, provide reassurance, and focus on building trust before delivering education.",
+        "status": "active"
+      },
+      {
+        "type": "cognitive_impairment",
+        "description": "Patient may present as slightly drowsy or confused due to recent hospitalization and medication changes. Speak slowly, repeat information, and confirm understanding frequently.",
+        "status": "active"
+      }
+    ]
+  }
+}
diff --git a/list/tenants/usf_sim_lab/scenarios/bob_barker_low_literacy.json b/list/tenants/usf_sim_lab/scenarios/bob_barker_low_literacy.json
new file mode 100644
index 0000000000000000000000000000000000000000..334ee7cf86585abc519a574ffb4b943d6a371151
--- /dev/null
+++ b/list/tenants/usf_sim_lab/scenarios/bob_barker_low_literacy.json
@@ -0,0 +1,132 @@
+{
+  "scenario_id": "bob_barker_low_literacy",
+  "patient_name": "Bob Barker",
+  "patient_dob": "1958-03-15",
+  "education_domain": "copd_education",
+  "archetype": "low_health_literacy",
+  "agenda_sequence": [
+    "edu_intro",
+    "diagnosis_understanding",
+    "smoking_cessation",
+    "nicotine_patch_use",
+    "summary_note"
+  ],
+  "patient_context": {
+    "age": 68,
+    "sex": "male",
+    "active_conditions": [
+      {
+        "code": "J44.1",
+        "display": "Chronic obstructive pulmonary disease with acute exacerbation",
+        "system": "ICD-10-CM",
+        "status": "active",
+        "category": "encounter-diagnosis"
+      },
+      {
+        "code": "F17.210",
+        "display": "Nicotine dependence, cigarettes, uncomplicated",
+        "system": "ICD-10-CM",
+        "status": "active",
+        "category": "problem-list-item"
+      },
+      {
+        "code": "I10",
+        "display": "Essential (primary) hypertension",
+        "system": "ICD-10-CM",
+        "status": "active",
+        "category": "problem-list-item"
+      }
+    ],
+    "active_medications": [
+      {
+        "name": "Nicotine Patch",
+        "dose": "21mg/24hr",
+        "frequency": "daily",
+        "route": "topical",
+        "is_high_risk": false,
+        "instructions": "Step-down schedule: 21mg x 4 weeks, then 14mg x 2 weeks, then 7mg x 2 weeks. 8-week course total."
+      },
+      {
+        "name": "Albuterol MDI (SABA)",
+        "dose": "90mcg/puff, 2 puffs",
+        "frequency": "PRN",
+        "route": "inhaled",
+        "is_high_risk": false,
+        "instructions": "Use as needed for shortness of breath. Shake well before each use."
+      },
+      {
+        "name": "Tiotropium (Spiriva) (LAMA)",
+        "dose": "18mcg",
+        "frequency": "daily",
+        "route": "inhaled",
+        "is_high_risk": false,
+        "instructions": "Use once daily for long-term airway maintenance."
+      }
+    ],
+    "clinical_summary": {
+      "smoking_history": "40 pack-year history (1 pack/day x 40 years). Current smoker at admission.",
+      "spirometry": "FEV1 52% predicted (GOLD Grade 2 - moderate airflow obstruction). FEV1/FVC 0.58 post-bronchodilator.",
+      "gold_classification": "GOLD Grade 2, Group E (moderate obstruction with recent exacerbation)",
+      "vital_signs_at_discharge": {
+        "heart_rate": 82,
+        "respiratory_rate": 20,
+        "blood_pressure": "138/84",
+        "oxygen_saturation": 93,
+        "temperature": 98.2
+      }
+    },
+    "discharge_info": {
+      "diagnosis_code": "J44.1",
+      "diagnosis_display": "COPD with acute exacerbation",
+      "discharge_date": "2026-02-27T10:00:00",
+      "discharge_medications": [
+        {
+          "name": "Nicotine Patch",
+          "dose": "21mg/24hr",
+          "frequency": "daily",
+          "route": "topical",
+          "is_high_risk": false
+        },
+        {
+          "name": "Albuterol MDI (SABA)",
+          "dose": "90mcg/puff, 2 puffs",
+          "frequency": "PRN",
+          "route": "inhaled",
+          "is_high_risk": false
+        },
+        {
+          "name": "Tiotropium (Spiriva) (LAMA)",
+          "dose": "18mcg",
+          "frequency": "daily",
+          "route": "inhaled",
+          "is_high_risk": false
+        }
+      ],
+      "discharge_instructions": "Apply nicotine patch daily, rotate site. Avoid smoking. Use rescue inhaler (albuterol) as needed for shortness of breath. Continue tiotropium daily. Follow up with pulmonology in 1 week.",
+      "length_of_stay_days": 3,
+      "discharge_disposition": "home"
+    },
+    "upcoming_appointments": [
+      {
+        "type": "follow_up",
+        "provider": "Dr. Patel, Pulmonology",
+        "date": "2026-03-06T14:00:00",
+        "location": "USF Health Pulmonology Clinic",
+        "status": "scheduled",
+        "visit_reason": "Post-discharge COPD follow-up"
+      }
+    ],
+    "known_barriers": [
+      {
+        "type": "health_literacy",
+        "description": "Patient has low health literacy. Use simple language, avoid medical jargon, repeat key points, and use teach-back to confirm understanding.",
+        "status": "active"
+      },
+      {
+        "type": "cognitive_impairment",
+        "description": "Patient may present as slightly drowsy or confused due to recent hospitalization and medication changes. Speak slowly, repeat information, and confirm understanding frequently.",
+        "status": "active"
+      }
+    ]
+  }
+}
diff --git a/list/tenants/usf_sim_lab/scenarios/sean_white_anxious.json b/list/tenants/usf_sim_lab/scenarios/sean_white_anxious.json
new file mode 100644
index 0000000000000000000000000000000000000000..e5d5b20f7a43b86482955e6f5a2110c95f7ceca1
--- /dev/null
+++ b/list/tenants/usf_sim_lab/scenarios/sean_white_anxious.json
@@ -0,0 +1,96 @@
+{
+  "scenario_id": "sean_white_anxious",
+  "patient_name": "Sean White",
+  "patient_dob": "1981-07-22",
+  "education_domain": "dvt_education",
+  "archetype": "anxious",
+  "agenda_sequence": [
+    "edu_intro",
+    "diagnosis_understanding",
+    "anticoagulation_therapy",
+    "bleeding_precautions",
+    "summary_note"
+  ],
+  "patient_context": {
+    "age": 45,
+    "sex": "male",
+    "active_conditions": [
+      {
+        "code": "I82.411",
+        "display": "Acute embolism and thrombosis of right femoral vein",
+        "system": "ICD-10-CM",
+        "status": "active",
+        "category": "encounter-diagnosis"
+      }
+    ],
+    "active_medications": [
+      {
+        "name": "Warfarin",
+        "dose": "5mg",
+        "frequency": "daily",
+        "route": "oral",
+        "is_high_risk": true,
+        "therapeutic_class": "anticoagulant"
+      }
+    ],
+    "recent_lab_results": [
+      {
+        "name": "INR",
+        "value": "1.8",
+        "unit": "",
+        "reference_range": "2.0-3.0",
+        "date": "2026-02-27T08:00:00",
+        "flag": "below_target"
+      },
+      {
+        "name": "D-dimer",
+        "value": "2.4",
+        "unit": "mg/L FEU",
+        "reference_range": "<0.5",
+        "date": "2026-02-25T14:00:00",
+        "flag": "high"
+      }
+    ],
+    "assessment_findings": [
+      "Right lower extremity swelling and tenderness",
+      "Positive compression ultrasonography of right femoral vein",
+      "Calf circumference 3 cm greater on right than left",
+      "No signs of pulmonary embolism at discharge"
+    ],
+    "discharge_info": {
+      "diagnosis_code": "I82.411",
+      "diagnosis_display": "Acute DVT, right femoral vein",
+      "discharge_date": "2026-02-27T10:00:00",
+      "discharge_medications": [
+        {
+          "name": "Warfarin",
+          "dose": "5mg",
+          "frequency": "daily",
+          "route": "oral",
+          "is_high_risk": true,
+          "therapeutic_class": "anticoagulant"
+        }
+      ],
+      "discharge_instructions": "Take warfarin 5mg daily at the same time each day. Target INR range is 2.0-3.0. Have INR checked in 3-5 days, then as directed. Expected treatment duration is 3-6 months. Watch for signs of bleeding (unusual bruising, dark stools, blood in urine). Seek emergency care for sudden shortness of breath, chest pain, or rapid heartbeat. Follow up with hematology in 1 week.",
+      "length_of_stay_days": 2,
+      "discharge_disposition": "home"
+    },
+    "upcoming_appointments": [
+      {
+        "type": "follow_up",
+        "provider": "Dr. Chen, Hematology",
+        "date": "2026-03-06T10:00:00",
+        "location": "USF Health Hematology Clinic",
+        "status": "scheduled",
+        "visit_reason": "Post-discharge DVT follow-up and INR check"
+      }
+    ],
+    "known_barriers": [
+      {
+        "type": "anxiety",
+        "description": "Patient is highly anxious and distrustful of the healthcare system. Validate feelings, do not rush, provide reassurance, and focus on building trust before delivering education.",
+        "status": "active"
+      }
+    ]
+  }
+}
diff --git a/list/tenants/usf_sim_lab/scenarios/sean_white_low_literacy.json b/list/tenants/usf_sim_lab/scenarios/sean_white_low_literacy.json
new file mode 100644
index 0000000000000000000000000000000000000000..c4fa162805431ea1d3a642573039df1f0426219d
--- /dev/null
+++ b/list/tenants/usf_sim_lab/scenarios/sean_white_low_literacy.json
@@ -0,0 +1,96 @@
+{
+  "scenario_id": "sean_white_low_literacy",
+  "patient_name": "Sean White",
+  "patient_dob": "1981-07-22",
+  "education_domain": "dvt_education",
+  "archetype": "low_health_literacy",
+  "agenda_sequence": [
+    "edu_intro",
+    "diagnosis_understanding",
+    "anticoagulation_therapy",
+    "bleeding_precautions",
+    "summary_note"
+  ],
+  "patient_context": {
+    "age": 45,
+    "sex": "male",
+    "active_conditions": [
+      {
+        "code": "I82.411",
+        "display": "Acute embolism and thrombosis of right femoral vein",
+        "system": "ICD-10-CM",
+        "status": "active",
+        "category": "encounter-diagnosis"
+      }
+    ],
+    "active_medications": [
+      {
+        "name": "Warfarin",
+        "dose": "5mg",
+        "frequency": "daily",
+        "route": "oral",
+        "is_high_risk": true,
+        "therapeutic_class": "anticoagulant"
+      }
+    ],
+    "recent_lab_results": [
+      {
+        "name": "INR",
+        "value": "1.8",
+        "unit": "",
+        "reference_range": "2.0-3.0",
+        "date": "2026-02-27T08:00:00",
+        "flag": "below_target"
+      },
+      {
+        "name": "D-dimer",
+        "value": "2.4",
+        "unit": "mg/L FEU",
+        "reference_range": "<0.5",
+        "date": "2026-02-25T14:00:00",
+        "flag": "high"
+      }
+    ],
+    "assessment_findings": [
+      "Right lower extremity swelling and tenderness",
+      "Positive compression ultrasonography of right femoral vein",
+      "Calf circumference 3 cm greater on right than left",
+      "No signs of pulmonary embolism at discharge"
+    ],
+    "discharge_info": {
+      "diagnosis_code": "I82.411",
+      "diagnosis_display": "Acute DVT, right femoral vein",
+      "discharge_date": "2026-02-27T10:00:00",
+      "discharge_medications": [
+        {
+          "name": "Warfarin",
+          "dose": "5mg",
+          "frequency": "daily",
+          "route": "oral",
+          "is_high_risk": true,
+          "therapeutic_class": "anticoagulant"
+        }
+      ],
+      "discharge_instructions": "Take warfarin 5mg daily at the same time each day. Target INR range is 2.0-3.0. Have INR checked in 3-5 days, then as directed. Expected treatment duration is 3-6 months. Watch for signs of bleeding (unusual bruising, dark stools, blood in urine). Seek emergency care for sudden shortness of breath, chest pain, or rapid heartbeat. Follow up with hematology in 1 week.",
+      "length_of_stay_days": 2,
+      "discharge_disposition": "home"
+    },
+    "upcoming_appointments": [
+      {
+        "type": "follow_up",
+        "provider": "Dr. Chen, Hematology",
+        "date": "2026-03-06T10:00:00",
+        "location": "USF Health Hematology Clinic",
+        "status": "scheduled",
+        "visit_reason": "Post-discharge DVT follow-up and INR check"
+      }
+    ],
+    "known_barriers": [
+      {
+        "type": "health_literacy",
+        "description": "Patient has low health literacy. Use simple language, avoid medical jargon, repeat key points, and use teach-back to confirm understanding.",
+        "status": "active"
+      }
+    ]
+  }
+}
diff --git a/list/tenants/usf_sim_lab/tenant.yaml b/list/tenants/usf_sim_lab/tenant.yaml
new file mode 100644
index 0000000000000000000000000000000000000000..bd39516304315338e49d0085dce516aa9fe5ddb3
--- /dev/null
+++ b/list/tenants/usf_sim_lab/tenant.yaml
@@ -0,0 +1,44 @@
+tenant_id: usf_sim_lab
+tenant_name: "USF College of Nursing - Simulation Lab"
+
+enabled_wedges:
+  - sim_education
+
+enabled_journeys:
+  - sim_lab_education
+
+custom_escalation_rules: []
+
+institution_context:
+  name: "USF Health"
+  type: academic_medical_center
+  nurse_line_number: "813-974-2201"
+  ed_name: "USF Health Emergency Department"
+  ehr_system: other
+  timezone: "America/New_York"
+
+data_source_config:
+  auth_method: api_key
+
+branding:
+  institution_name: "USF Health"
+  caller_introduction: "Hi, this is Avery calling from USF Health."
+  nurse_line_label: "the USF Health nurse line"
+  emergency_instructions: "call 911 or go to the nearest emergency department"
+
+domain_overrides:
+  acute_confusion:
+    enabled: false
+  copd_exacerbation:
+    enabled: false
+  severe_bleeding:
+    enabled: false
+  gi_bleed:
+    enabled: false
+  anticoagulation_monitoring:
+    enabled: false
+
+compliance_settings:
+  audit_retention_days: 2555
+  phi_logging_enabled: false
+  require_consent_recording: false
diff --git a/requirements-serve.txt b/requirements-serve.txt
new file mode 100644
index 0000000000000000000000000000000000000000..57eb670c2a3fa071e147f1ba3498fcb6c2f1a634
--- /dev/null
+++ b/requirements-serve.txt
@@ -0,0 +1,16 @@
+# Serving-only dependencies (no torch/training libs needed)
+# ONNX Runtime for inference
+onnxruntime>=1.16.0
+transformers>=4.36.0
+
+# Web framework
+fastapi>=0.109.0
+uvicorn[standard]>=0.27.0
+pydantic>=2.5.0
+
+# Utilities
+numpy>=1.24.0
+pyyaml>=6.0
+bleach>=6.1.0
+slowapi>=0.1.9
+httpx>=0.26.0
diff --git a/service/__init__.py b/service/__init__.py
new file mode 100644
index 0000000000000000000000000000000000000000..88f04e4cb74947de57d440ab142fa26618d12e01
--- /dev/null
+++ b/service/__init__.py
@@ -0,0 +1 @@
+"""DCE Intent Classifier Service Package."""
diff --git a/service/app.py b/service/app.py
new file mode 100644
index 0000000000000000000000000000000000000000..669201b0d3a81042c6a15fa8e9103942a22cdb51
--- /dev/null
+++ b/service/app.py
@@ -0,0 +1,2764 @@
+#!/usr/bin/env python3
+"""
+FastAPI Inference Service for DCE Intent BioClinicalBERT.
+
+Low-latency inference using ONNX Runtime INT8 quantized model.
+Scalability features: async inference, connection pooling, metrics, batching.
+
+Usage:
+    API_KEY=your-secret-key uvicorn service.app:app --host 0.0.0.0 --port 8000
+    
+    # Or specify a different port:
+    API_KEY=your-secret-key uvicorn service.app:app --host 0.0.0.0 --port 8001
+    
+    # Production with multiple workers:
+    API_KEY=your-secret-key gunicorn service.app:app -w 4 -k uvicorn.workers.UvicornWorker
+"""
+
+import asyncio
+import hashlib
+import json
+import logging
+import os
+import re
+import secrets
+import signal
+import sys
+import threading
+import time
+import uuid
+from collections import OrderedDict
+from concurrent.futures import ThreadPoolExecutor
+from contextlib import asynccontextmanager
+from contextvars import ContextVar
+from dataclasses import dataclass, field
+from datetime import datetime, timezone
+from pathlib import Path
+from typing import Any, Dict, List, Optional, Tuple
+
+import bleach
+import numpy as np
+import onnxruntime as ort
+from fastapi import Depends, FastAPI, HTTPException, Query, Request, Security, status
+from fastapi.middleware.cors import CORSMiddleware
+from fastapi.responses import JSONResponse
+from fastapi.security import APIKeyHeader
+from pydantic import BaseModel, Field, field_validator
+from slowapi import Limiter, _rate_limit_exceeded_handler
+from slowapi.errors import RateLimitExceeded
+from slowapi.util import get_remote_address
+from transformers import AutoTokenizer
+
+# Import HIPAA compliance utilities
+try:
+    from service.hipaa_config import (
+        hipaa_audit,
+        redact_phi,
+        check_clinical_safety_keywords,
+        get_security_headers,
+        get_compliance_status,
+        REQUIRE_TLS,
+    )
+    HIPAA_ENABLED = True
+except ImportError:
+    HIPAA_ENABLED = False
+
+# Import Temporal Preprocessor
+try:
+    from service.temporal_preprocessor import preprocess_temporal, TemporalSignal
+    TEMPORAL_PREPROCESSOR_AVAILABLE = True
+except ImportError:
+    TEMPORAL_PREPROCESSOR_AVAILABLE = False
+
+# Import Taxonomy Scorer
+try:
+    from service.taxonomy_scorer import score_taxonomy, TaxonomyScoreResult
+    TAXONOMY_SCORER_AVAILABLE = True
+except ImportError:
+    TAXONOMY_SCORER_AVAILABLE = False
+
+# Import Decision Engine (Phase 1: Safety Trifecta)
+try:
+    from decision.engine.config_loader import DecisionConfigLoader
+    from decision.engine.trigger_engine import TaxonomyTriggerEngine
+    from decision.engine.domain_nomination import DomainNominator
+    from decision.engine.risk_classifier import RiskClassifier
+    from decision.engine.models import RiskClass, ConfidenceTier, RiskAssessment
+    from decision.engine.flow_engine import FlowEngine, TurnResult
+    from decision.engine.fhir_context import PatientContextBuilder
+    from decision.engine.tenant_manager import TenantManager
+    from decision.engine.journey_orchestrator import JourneyOrchestrator
+    DECISION_ENGINE_AVAILABLE = True
+except ImportError as _de_err:
+    DECISION_ENGINE_AVAILABLE = False
+    logger.warning("Decision engine not available: %s", _de_err)
+
+# =============================================================================
+# CONTEXT VARIABLES FOR THREAD-SAFE LOGGING
+# =============================================================================
+
+request_id_var: ContextVar[str] = ContextVar("request_id", default="-")
+client_ip_var: ContextVar[str] = ContextVar("client_ip", default="-")
+
+
+class RequestContextFilter(logging.Filter):
+    """Add request context to log records using context variables (thread-safe)."""
+    def filter(self, record):
+        record.request_id = request_id_var.get()
+        record.client_ip = client_ip_var.get()
+        return True
+
+
+logging.basicConfig(
+    level=logging.INFO,
+    format="%(asctime)s - %(name)s - %(levelname)s - [%(request_id)s] [%(client_ip)s] - %(message)s",
+)
+logger = logging.getLogger(__name__)
+logger.addFilter(RequestContextFilter())
+
+# Audit logger for security events
+audit_logger = logging.getLogger("audit")
+audit_logger.setLevel(logging.INFO)
+audit_logger.addFilter(RequestContextFilter())
+
+# =============================================================================
+# SECURITY CONFIGURATION
+# =============================================================================
+
+# API Key Authentication
+API_KEY = os.getenv("API_KEY", "")  # Required in production
+API_KEY_HEADER = APIKeyHeader(name="X-API-Key", auto_error=False)
+REQUIRE_AUTH = os.getenv("REQUIRE_AUTH", "false").lower() == "true"
+
+# Rate Limiting Configuration
+RATE_LIMIT = os.getenv("RATE_LIMIT", "100/minute")  # Requests per minute
+# Use Redis for multi-worker deployments: redis://localhost:6379
+# Falls back to memory for single-worker or development
+RATE_LIMIT_STORAGE_URI = os.getenv("RATE_LIMIT_STORAGE", "memory://")
+if "gunicorn" in os.getenv("SERVER_SOFTWARE", "") and RATE_LIMIT_STORAGE_URI == "memory://":
+    logger.warning("Rate limiting with memory storage won't work across gunicorn workers. Set RATE_LIMIT_STORAGE=redis://...")
+
+# CORS Configuration - comma-separated list of allowed origins
+ALLOWED_ORIGINS = os.getenv("ALLOWED_ORIGINS", "http://localhost:3000,http://localhost:8080").split(",")
+ALLOWED_ORIGINS = [origin.strip() for origin in ALLOWED_ORIGINS if origin.strip()]
+
+# Path validation - allowed base directories for model loading
+ALLOWED_MODEL_PATHS = [
+    Path("artifacts").resolve(),
+    Path(os.getenv("ALLOWED_MODEL_BASE", "artifacts")).resolve(),
+]
+
+# =============================================================================
+# SCALABILITY CONFIGURATION
+# =============================================================================
+
+# Thread pool for CPU-bound inference (prevents blocking async event loop)
+INFERENCE_WORKERS = int(os.getenv("INFERENCE_WORKERS", "4"))
+inference_executor: Optional[ThreadPoolExecutor] = None
+
+# ONNX Runtime session configuration
+ONNX_INTRA_OP_THREADS = int(os.getenv("ONNX_INTRA_OP_THREADS", "4"))
+ONNX_INTER_OP_THREADS = int(os.getenv("ONNX_INTER_OP_THREADS", "1"))
+ONNX_GRAPH_OPT_LEVEL = os.getenv("ONNX_GRAPH_OPT_LEVEL", "all")  # all, basic, extended, disabled
+
+# Request batching configuration (optional, for high-throughput scenarios)
+ENABLE_BATCHING = os.getenv("ENABLE_BATCHING", "false").lower() == "true"
+BATCH_SIZE = int(os.getenv("BATCH_SIZE", "8"))
+BATCH_TIMEOUT_MS = int(os.getenv("BATCH_TIMEOUT_MS", "10"))
+
+# Metrics configuration
+ENABLE_METRICS = os.getenv("ENABLE_METRICS", "true").lower() == "true"
+
+# Request timeout configuration (seconds)
+INFERENCE_TIMEOUT_SECONDS = float(os.getenv("INFERENCE_TIMEOUT", "30.0"))
+
+# Request body size limit (bytes) - prevents DoS via large payloads
+MAX_REQUEST_BODY_SIZE = int(os.getenv("MAX_REQUEST_BODY_SIZE", str(1024 * 1024)))  # 1MB default
+
+# Default decision policy constants (used when policy file not found)
+DEFAULT_ESCALATION_LABEL = "ESCALATION"
+DEFAULT_ESCALATION_THRESHOLD = 0.5
+DEFAULT_MIN_CONFIDENCE = 0.3
+DEFAULT_FALLBACK_LABEL = "OTHER"
+
+# =============================================================================
+# METRICS TRACKING
+# =============================================================================
+
+@dataclass
+class ServiceMetrics:
+    """Thread-safe metrics for monitoring service performance."""
+    total_requests: int = 0
+    successful_requests: int = 0
+    failed_requests: int = 0
+    total_inference_time_ms: float = 0.0
+    total_tokenize_time_ms: float = 0.0
+    escalations_triggered: int = 0
+    start_time: float = field(default_factory=time.time)
+    _lock: Any = field(default_factory=lambda: __import__('threading').Lock())
+    
+    def record_request(self, success: bool, inference_ms: float, tokenize_ms: float, escalated: bool):
+        """Record metrics for a request (thread-safe with lock)."""
+        with self._lock:
+            self.total_requests += 1
+            if success:
+                self.successful_requests += 1
+            else:
+                self.failed_requests += 1
+            self.total_inference_time_ms += inference_ms
+            self.total_tokenize_time_ms += tokenize_ms
+            if escalated:
+                self.escalations_triggered += 1
+    
+    def get_stats(self) -> Dict[str, Any]:
+        """Get current metrics as dictionary."""
+        uptime = time.time() - self.start_time
+        avg_inference = self.total_inference_time_ms / max(1, self.successful_requests)
+        avg_tokenize = self.total_tokenize_time_ms / max(1, self.successful_requests)
+        return {
+            "uptime_seconds": round(uptime, 2),
+            "total_requests": self.total_requests,
+            "successful_requests": self.successful_requests,
+            "failed_requests": self.failed_requests,
+            "success_rate": round(self.successful_requests / max(1, self.total_requests), 4),
+            "escalations_triggered": self.escalations_triggered,
+            "avg_inference_ms": round(avg_inference, 3),
+            "avg_tokenize_ms": round(avg_tokenize, 3),
+            "requests_per_second": round(self.total_requests / max(1, uptime), 2),
+        }
+
+
+metrics = ServiceMetrics()
+
+# =============================================================================
+# MODEL CONFIGURATION
+# =============================================================================
+
+def validate_path(path: Path, allowed_bases: List[Path]) -> Path:
+    """Validate that a path is within allowed directories (prevent traversal)."""
+    resolved = path.resolve()
+    for base in allowed_bases:
+        try:
+            resolved.relative_to(base)
+            return resolved
+        except ValueError:
+            continue
+    raise ValueError(f"Path {path} is not within allowed directories")
+
+# Configuration from environment with path validation
+_model_dir_raw = Path(os.getenv("MODEL_DIR", "artifacts/onnx_int8"))
+_environment = os.getenv("ENVIRONMENT", "development").lower()
+try:
+    MODEL_DIR = validate_path(_model_dir_raw, ALLOWED_MODEL_PATHS)
+except ValueError:
+    if _environment == "production":
+        raise RuntimeError(
+            f"MODEL_DIR path validation failed for '{_model_dir_raw}'. "
+            "In production, MODEL_DIR must be within allowed model paths."
+        )
+    # Fall back to default only in non-production
+    MODEL_DIR = Path("artifacts/onnx_int8").resolve()
+    logger.warning(f"MODEL_DIR path validation failed, using default: {MODEL_DIR}")
+
+_policy_path_raw = Path(os.getenv("POLICY_PATH", "artifacts/config/decision_policy.json"))
+try:
+    POLICY_PATH = validate_path(_policy_path_raw, ALLOWED_MODEL_PATHS)
+except ValueError:
+    if _environment == "production":
+        raise RuntimeError(
+            f"POLICY_PATH path validation failed for '{_policy_path_raw}'. "
+            "In production, POLICY_PATH must be within allowed model paths."
+        )
+    POLICY_PATH = Path("artifacts/config/decision_policy.json").resolve()
+    logger.warning(f"POLICY_PATH path validation failed, using default: {POLICY_PATH}")
+
+MAX_LENGTH = int(os.getenv("MAX_LENGTH", "64"))  # Match v4 BioClinicalBERT training config
+MAX_INPUT_CHARS = int(os.getenv("MAX_INPUT_CHARS", "1024"))
+MAX_COMBINED_CHARS = int(os.getenv("MAX_COMBINED_CHARS", "1500"))  # text + context limit
+
+# =============================================================================
+# RATE LIMITER SETUP
+# =============================================================================
+
+limiter = Limiter(key_func=get_remote_address)
+
+# =============================================================================
+# FASTAPI APPLICATION
+# =============================================================================
+
+# Conditionally disable docs in production
+DISABLE_DOCS = os.getenv("DISABLE_DOCS", "false").lower() == "true"
+
+app = FastAPI(
+    title="Medical Intent Escalation",
+    description="DCE version 1.0.0",
+    version="1.0.0",
+    docs_url=None if DISABLE_DOCS else "/docs",
+    redoc_url=None if DISABLE_DOCS else "/redoc",
+    openapi_url=None if DISABLE_DOCS else "/openapi.json",
+)
+
+# Add rate limiter to app
+app.state.limiter = limiter
+app.add_exception_handler(RateLimitExceeded, _rate_limit_exceeded_handler)
+
+# CORS middleware with restricted origins
+app.add_middleware(
+    CORSMiddleware,
+    allow_origins=ALLOWED_ORIGINS,
+    allow_credentials=True,
+    allow_methods=["POST", "GET"],
+    allow_headers=["X-API-Key", "Content-Type", "Authorization"],
+)
+
+
+@app.middleware("http")
+async def limit_request_body_size(request: Request, call_next):
+    """Middleware to limit request body size and prevent DoS via large payloads."""
+    content_length = request.headers.get("content-length")
+    if content_length:
+        try:
+            if int(content_length) > MAX_REQUEST_BODY_SIZE:
+                return JSONResponse(
+                    status_code=413,
+                    content={"detail": f"Request body too large. Max size: {MAX_REQUEST_BODY_SIZE} bytes"},
+                )
+        except ValueError:
+            pass  # Invalid content-length header, let request proceed
+    return await call_next(request)
+
+
+# =============================================================================
+# AUTHENTICATION
+# =============================================================================
+
+async def verify_api_key(api_key: Optional[str] = Security(API_KEY_HEADER)) -> Optional[str]:
+    """
+    Verify API key from header.
+    
+    Returns the API key if valid, raises HTTPException if invalid.
+    """
+    if not REQUIRE_AUTH:
+        return None  # Auth disabled
+    
+    if not API_KEY:
+        logger.warning("API_KEY not configured but REQUIRE_AUTH=true")
+        raise HTTPException(
+            status_code=status.HTTP_500_INTERNAL_SERVER_ERROR,
+            detail="Server authentication not configured",
+        )
+    
+    if not api_key:
+        audit_logger.warning("Missing API key in request")
+        raise HTTPException(
+            status_code=status.HTTP_401_UNAUTHORIZED,
+            detail="Missing API key",
+            headers={"WWW-Authenticate": "ApiKey"},
+        )
+    
+    # Use constant-time comparison to prevent timing attacks
+    if not secrets.compare_digest(api_key, API_KEY):
+        audit_logger.warning(f"Invalid API key attempt: {hashlib.sha256(api_key.encode()).hexdigest()[:16]}...")
+        raise HTTPException(
+            status_code=status.HTTP_401_UNAUTHORIZED,
+            detail="Invalid API key",
+            headers={"WWW-Authenticate": "ApiKey"},
+        )
+    
+    return api_key
+
+
+# =============================================================================
+# REQUEST CONTEXT MIDDLEWARE
+# =============================================================================
+
+@app.middleware("http")
+async def add_request_context(request: Request, call_next):
+    """Add request ID and client IP to all requests for audit logging (thread-safe)."""
+    request_id = request.headers.get("X-Request-ID", str(uuid.uuid4())[:8])
+    client_ip = request.client.host if request.client else "unknown"
+    
+    # Store in request state for access in endpoints
+    request.state.request_id = request_id
+    request.state.client_ip = client_ip
+    
+    # Set context variables (thread-safe, no global state mutation)
+    request_id_token = request_id_var.set(request_id)
+    client_ip_token = client_ip_var.set(client_ip)
+    
+    try:
+        # Log request
+        audit_logger.info(f"Request: {request.method} {request.url.path}")
+        
+        start_time = time.perf_counter()
+        response = await call_next(request)
+        duration_ms = (time.perf_counter() - start_time) * 1000
+        
+        # Add request ID to response headers
+        response.headers["X-Request-ID"] = request_id
+        
+        # Add security headers for HIPAA compliance
+        if HIPAA_ENABLED:
+            # Use relaxed headers for docs endpoints
+            is_docs = request.url.path in ["/docs", "/redoc", "/openapi.json"]
+            for header_name, header_value in get_security_headers(is_docs=is_docs).items():
+                response.headers[header_name] = header_value
+        
+        # Log response
+        audit_logger.info(f"Response: {response.status_code} ({duration_ms:.2f}ms)")
+        
+        return response
+    finally:
+        # Reset context variables
+        request_id_var.reset(request_id_token)
+        client_ip_var.reset(client_ip_token)
+
+# Global model resources (loaded at startup)
+tokenizer: Optional[AutoTokenizer] = None
+session: Optional[ort.InferenceSession] = None
+label2id: Dict[str, int] = {}
+id2label: Dict[int, str] = {}
+decision_policy: Dict[str, Any] = {}
+
+# Decision Engine globals (Phase 1: Safety Trifecta)
+decision_config: Optional[Any] = None       # DecisionConfigLoader
+trigger_engine: Optional[Any] = None        # TaxonomyTriggerEngine
+domain_nominator: Optional[Any] = None      # DomainNominator
+risk_classifier: Optional[Any] = None       # RiskClassifier
+flow_engine: Optional[Any] = None           # FlowEngine (Phase 2)
+tenant_manager: Optional[Any] = None       # TenantManager (Phase 3)
+journey_orch: Optional[Any] = None         # JourneyOrchestrator (Phase 3)
+context_builder: Optional[Any] = None      # PatientContextBuilder (Phase 3)
+
+
+class PredictRequest(BaseModel):
+    """Request schema for /predict endpoint."""
+    text: str = Field(..., min_length=1, max_length=MAX_INPUT_CHARS, description="Input text to classify")
+    context: Optional[str] = Field(None, max_length=MAX_INPUT_CHARS, description="Optional conversation context")
+    
+    @field_validator("text", "context", mode="before")
+    @classmethod
+    def sanitize_input(cls, v: Optional[str]) -> Optional[str]:
+        """Sanitize input to prevent injection attacks."""
+        if v is None:
+            return None
+        # Strip HTML/script tags
+        v = bleach.clean(v, tags=[], strip=True)
+        # Normalize whitespace
+        v = " ".join(v.split())
+        # Remove null bytes and other control characters
+        v = v.replace("\x00", "").replace("\r", "")
+        return v
+    
+    def validate_combined_length(self) -> None:
+        """Validate that text + context doesn't exceed combined limit."""
+        text_len = len(self.text) if self.text else 0
+        context_len = len(self.context) if self.context else 0
+        if text_len + context_len > MAX_COMBINED_CHARS:
+            raise ValueError(
+                f"Combined text and context length ({text_len + context_len}) "
+                f"exceeds maximum ({MAX_COMBINED_CHARS})"
+            )
+
+
+class TimingInfo(BaseModel):
+    """Timing breakdown for the prediction."""
+    tokenize_ms: float
+    inference_ms: float
+    postprocess_ms: float
+    total_ms: float
+
+
+class TaxonomyMatchDetail(BaseModel):
+    """Detail for a single matched taxonomy domain."""
+    domain: str
+    score: float = Field(..., description="Deterministic match score 0.0-1.0")
+    confidence_tier: str = Field(..., description="high/medium/low/none")
+    priority: int = Field(0, description="Domain clinical priority")
+    is_negated: bool = False
+    target_risk_class: Optional[str] = None
+    recommended_flow: Optional[str] = None
+    trigger_count: int = 0
+    matched_phrases: List[str] = Field(default_factory=list)
+
+
+class PredictResponse(BaseModel):
+    """Response schema for /predict endpoint."""
+    predicted_label: str
+    probabilities: Dict[str, float]
+    taxonomy_scores: Dict[str, float] = Field(default_factory=dict, description="Deterministic match scores for all taxonomy domains")
+    matched_taxonomy: List[TaxonomyMatchDetail] = Field(default_factory=list, description="Taxonomy domains that matched with details")
+    top_taxonomy_domain: Optional[str] = Field(None, description="Highest-scoring taxonomy domain")
+    should_escalate: bool
+    escalation_probability: float
+    confidence: float
+    decision_reason: str
+    timing: TimingInfo
+    model_version: str = "1.0.0"
+
+
+class DomainNominationResponse(BaseModel):
+    """A single domain nomination in the clinical assessment."""
+    domain: str
+    confidence_tier: str
+    priority: int
+    target_risk_class: Optional[str] = None
+    is_negated: bool = False
+    recommended_flow: Optional[str] = None
+    trigger_match_count: int = 0
+
+
+class ClinicalAssessmentResponse(BaseModel):
+    """Full clinical risk assessment response for /predict/clinical."""
+    # ML classification
+    predicted_label: str
+    probabilities: Dict[str, float]
+    ml_confidence: float
+    # Clinical risk assessment
+    risk_class: str = Field(..., description="R0/R1/R2/R3 clinical risk tier")
+    risk_description: str = Field(..., description="Human-readable risk description")
+    primary_domain: Optional[str] = Field(None, description="Primary clinical domain detected")
+    requires_911: bool = Field(False, description="Whether patient should be instructed to call 911")
+    requires_nurse_transfer: bool = Field(False, description="Whether a nurse transfer is needed")
+    hard_escalate: bool = Field(False, description="Whether hard-escalate domain triggered")
+    safety_override: bool = Field(False, description="Whether lexical safety signal overrode ML")
+    # Domain nominations
+    domain_nominations: List[DomainNominationResponse] = Field(default_factory=list)
+    # Taxonomy scores (deterministic)
+    taxonomy_scores: Dict[str, float] = Field(default_factory=dict, description="Deterministic match scores for all taxonomy domains")
+    matched_taxonomy: List[TaxonomyMatchDetail] = Field(default_factory=list, description="Taxonomy domains that matched with details")
+    top_taxonomy_domain: Optional[str] = Field(None, description="Highest-scoring taxonomy domain")
+    # Flow recommendation
+    recommended_flow: Optional[str] = None
+    recommended_action: Optional[str] = None
+    # Legacy compatibility
+    should_escalate: bool
+    escalation_probability: float
+    decision_reason: str
+    # Timing
+    timing: TimingInfo
+    model_version: str = "1.0.0"
+    engine_version: str = "phase1"
+
+
+class HealthResponse(BaseModel):
+    """Response schema for /health endpoint."""
+    status: str
+    model_loaded: bool
+    policy_loaded: bool
+    decision_engine_loaded: bool = False
+    timestamp: str
+
+
+def get_onnx_optimization_level(level: str) -> ort.GraphOptimizationLevel:
+    """Convert string optimization level to ONNX Runtime enum."""
+    levels = {
+        "disabled": ort.GraphOptimizationLevel.ORT_DISABLE_ALL,
+        "basic": ort.GraphOptimizationLevel.ORT_ENABLE_BASIC,
+        "extended": ort.GraphOptimizationLevel.ORT_ENABLE_EXTENDED,
+        "all": ort.GraphOptimizationLevel.ORT_ENABLE_ALL,
+    }
+    return levels.get(level.lower(), ort.GraphOptimizationLevel.ORT_ENABLE_ALL)
+
+
+def load_model() -> None:
+    """Load ONNX model, tokenizer, and decision policy."""
+    global tokenizer, session, label2id, id2label, decision_policy, inference_executor
+    
+    logger.info(f"Loading model from {MODEL_DIR}")
+    logger.info(f"ONNX config: intra_threads={ONNX_INTRA_OP_THREADS}, inter_threads={ONNX_INTER_OP_THREADS}, opt_level={ONNX_GRAPH_OPT_LEVEL}")
+    
+    # Initialize thread pool for async inference
+    inference_executor = ThreadPoolExecutor(
+        max_workers=INFERENCE_WORKERS,
+        thread_name_prefix="inference_worker"
+    )
+    logger.info(f"Inference thread pool created with {INFERENCE_WORKERS} workers")
+    
+    # Load tokenizer
+    tokenizer = AutoTokenizer.from_pretrained(MODEL_DIR)
+    logger.info("Tokenizer loaded")
+    
+    # Load ONNX model
+    model_path = MODEL_DIR / "model.onnx"
+    if not model_path.exists():
+        raise FileNotFoundError(f"ONNX model not found: {model_path}")
+    
+    # Configure session options with environment-based settings
+    sess_options = ort.SessionOptions()
+    sess_options.graph_optimization_level = get_onnx_optimization_level(ONNX_GRAPH_OPT_LEVEL)
+    sess_options.intra_op_num_threads = ONNX_INTRA_OP_THREADS
+    sess_options.inter_op_num_threads = ONNX_INTER_OP_THREADS
+    
+    # Enable memory optimization for better scalability
+    sess_options.enable_mem_pattern = True
+    sess_options.enable_cpu_mem_arena = True
+    
+    session = ort.InferenceSession(
+        str(model_path),
+        sess_options,
+        providers=["CPUExecutionProvider"]
+    )
+    logger.info("ONNX session created with optimized settings")
+    
+    # Check quantization metadata - warn if model is not actually quantized
+    quant_meta_path = MODEL_DIR / "quantization_metadata.json"
+    if quant_meta_path.exists():
+        with open(quant_meta_path, "r", encoding="utf-8") as f:
+            quant_meta = json.load(f)
+        if not quant_meta.get("is_quantized", True):
+            logger.warning(
+                f"MODEL NOT QUANTIZED: The model in {MODEL_DIR} is an unquantized FP32 model "
+                f"despite being in a directory that implies INT8 quantization. "
+                f"Inference will be slower than expected. Re-run: python quantize_onnx.py"
+            )
+    
+    # Load label mappings
+    mappings_path = MODEL_DIR / "label_mappings.json"
+    if mappings_path.exists():
+        with open(mappings_path, "r", encoding="utf-8") as f:
+            mappings = json.load(f)
+        label2id = mappings["label2id"]
+        id2label = {int(k): v for k, v in mappings["id2label"].items()}
+        logger.info(f"Loaded {len(label2id)} labels")
+    else:
+        logger.warning("Label mappings not found, using defaults")
+    
+    # Load decision policy
+    if POLICY_PATH.exists():
+        with open(POLICY_PATH, "r", encoding="utf-8") as f:
+            decision_policy = json.load(f)
+        logger.info("Decision policy loaded")
+        
+        # Runtime safety guardrail: warn if calibrated recall is below minimum
+        SAFETY_MIN_RECALL = 0.85
+        cal_metrics = decision_policy.get("calibration_metrics", {})
+        policy_recall = cal_metrics.get("recall", None)
+        if policy_recall is not None and policy_recall < SAFETY_MIN_RECALL:
+            logger.warning(
+                f"SAFETY WARNING: Decision policy recall ({policy_recall:.3f}) is below "
+                f"the safety minimum ({SAFETY_MIN_RECALL:.3f}). "
+                f"{(1 - policy_recall) * 100:.1f}% of escalation cases may be missed. "
+                f"Recalibrate with: python calibrate.py --max_length 64"
+            )
+    else:
+        logger.warning(f"Decision policy not found at {POLICY_PATH}, using defaults")
+        decision_policy = {
+            "escalation_policy": {
+                "escalation_label": DEFAULT_ESCALATION_LABEL,
+                "escalation_threshold": DEFAULT_ESCALATION_THRESHOLD,
+            },
+            "confidence_policy": {
+                "min_confidence": DEFAULT_MIN_CONFIDENCE,
+                "fallback_label": DEFAULT_FALLBACK_LABEL,
+            },
+        }
+    
+    # Initialize Decision Engine (Phase 1: Safety Trifecta)
+    global decision_config, trigger_engine, domain_nominator, risk_classifier, flow_engine, tenant_manager, journey_orch, context_builder
+    if DECISION_ENGINE_AVAILABLE:
+        decision_dir = Path(__file__).resolve().parent.parent / "decision"
+        if decision_dir.is_dir():
+            try:
+                decision_config = DecisionConfigLoader(decision_dir)
+                decision_config.load_all()
+                # Load additional taxonomy domains from list/taxonomy/
+                list_taxonomy_dir = Path(__file__).resolve().parent.parent / "list" / "taxonomy"
+                if list_taxonomy_dir.is_dir():
+                    decision_config.load_additional_taxonomy(list_taxonomy_dir)
+                trigger_engine = TaxonomyTriggerEngine(decision_config)
+                domain_nominator = DomainNominator(decision_config, trigger_engine)
+                risk_classifier = RiskClassifier(decision_config)
+                flow_engine = FlowEngine(decision_config)
+                tenant_manager = TenantManager(decision_config)
+                journey_orch = JourneyOrchestrator(decision_config, tenant_manager)
+                context_builder = PatientContextBuilder(decision_config)
+                logger.info(
+                    "Decision engine initialized: %d domains, %d risk rules, %d suppression rules, "
+                    "%d tenants, %d journeys, flow engine ready",
+                    len(decision_config.domain_names),
+                    len(decision_config.risk_escalation_rules),
+                    len(decision_config.domain_suppression_rules),
+                    len(decision_config.tenants),
+                    len(decision_config.journeys),
+                )
+            except Exception as e:
+                logger.error("Failed to initialize decision engine: %s", e)
+                decision_config = None
+                trigger_engine = None
+                domain_nominator = None
+                risk_classifier = None
+        else:
+            logger.info("Decision config directory not found at %s, engine disabled", decision_dir)
+
+
+def softmax(x: np.ndarray) -> np.ndarray:
+    """Compute softmax probabilities from logits."""
+    x_shifted = x - np.max(x, axis=-1, keepdims=True)
+    exp_x = np.exp(x_shifted)
+    return exp_x / np.sum(exp_x, axis=-1, keepdims=True)
+
+
+# Safety keywords that ALWAYS trigger escalation regardless of model output
+# Each entry: (pattern, description, requires_negation_check)
+SAFETY_ESCALATION_PATTERNS = [
+    # Mental health - ALWAYS check for negation
+    (re.compile(r"\b(suicide|suicidal)\b", re.IGNORECASE), "suicide_mention", True),
+    (re.compile(r"\b(kill myself|end my life|want to die|kill me)\b", re.IGNORECASE), "self_harm_intent", True),
+    (re.compile(r"\b(hurt myself|self[- ]?harm|cutting myself)\b", re.IGNORECASE), "self_harm", True),
+    (re.compile(r"\b(overdose|od['']?d)\b", re.IGNORECASE), "overdose", True),
+    # Breathing - check for negation (e.g., "I'm not having trouble breathing")
+    (re.compile(r"\b(can'?t breathe|cannot breathe|not breathing|stop breathing)\b", re.IGNORECASE), "breathing_emergency", False),  # These phrases are already negative
+    (re.compile(r"\b(difficulty breathing|trouble breathing|hard to breathe)\b", re.IGNORECASE), "breathing_difficulty", True),
+    # Cardiac - check for negation
+    (re.compile(r"\b(chest\s+(pain|hurts?|pressure|tightness|burning|discomfort)|pain\s+in\s+(my\s+)?chest|heart\s+pain)\b", re.IGNORECASE), "chest_pain", True),
+    (re.compile(r"\b(heart attack|cardiac arrest)\b", re.IGNORECASE), "cardiac_emergency", True),
+    (re.compile(r"\b(stroke)\b", re.IGNORECASE), "stroke", True),
+    # Consciousness - check for negation
+    (re.compile(r"\b(unconscious|unresponsive|passed out)\b", re.IGNORECASE), "unconscious", True),
+    (re.compile(r"\b(seizure|convulsion)\b", re.IGNORECASE), "seizure", True),
+    # Bleeding - check for negation
+    (re.compile(r"\b(severe bleeding|bleeding (heavily|out|profusely)|hemorrhage|hemorrhaging)\b", re.IGNORECASE), "severe_bleeding", True),
+    # Allergic reaction - check for negation
+    (re.compile(r"\b(anaphylaxis|anaphylactic|severe allergic)\b", re.IGNORECASE), "anaphylaxis", True),
+    (re.compile(r"\b(throat.*(closing|swelling))\b", re.IGNORECASE), "throat_swelling", True),
+]
+
+# Negation patterns to check before safety keywords
+NEGATION_PATTERNS = [
+    re.compile(r"\b(not|no|don'?t|doesn'?t|didn'?t|haven'?t|hasn'?t|hadn'?t|won'?t|wouldn'?t|can'?t|cannot|never|without|ain'?t)\b", re.IGNORECASE),
+]
+
+# Context window for negation check (number of words before keyword)
+NEGATION_WINDOW_SIZE = 5
+
+# Historical/third-party patterns that indicate non-emergency context
+HISTORICAL_PATTERNS = [
+    re.compile(r"\b(my (friend|mother|father|brother|sister|husband|wife|son|daughter|grandma|grandpa|neighbor|coworker))\b", re.IGNORECASE),
+    re.compile(r"\b(last (year|month|week|time)|years? ago|previously|in the past|used to|history of)\b", re.IGNORECASE),
+    re.compile(r"\b(worried about|afraid of|scared of|fear of|thinking about whether)\b", re.IGNORECASE),
+]
+
+# Active-urgency patterns that OVERRIDE historical/proxy suppression.
+# When a proxy reference ("my mother") co-occurs with these acute signals,
+# the report should be treated as authoritative — do NOT suppress.
+PROXY_ACTIVE_URGENCY_PATTERNS = [
+    re.compile(r"\b(is\s+having|are\s+having|has\s+been\s+having)\b", re.IGNORECASE),
+    re.compile(r"\b(right\s+now|at\s+this\s+moment|currently|presently)\b", re.IGNORECASE),
+    re.compile(r"\b(can'?t\s+breathe|cannot\s+breathe|not\s+breathing|stopped\s+breathing)\b", re.IGNORECASE),
+    re.compile(r"\b(is\s+(bleeding|seizing|convulsing|choking|vomiting|fainting|unconscious|unresponsive))\b", re.IGNORECASE),
+    re.compile(r"\b(just\s+(collapsed|fainted|passed\s+out|fell|overdosed|seized))\b", re.IGNORECASE),
+    re.compile(r"\b(needs?\s+help|call\s+911|emergency|ambulance)\b", re.IGNORECASE),
+    re.compile(r"\b(what\s+should\s+(i|we|she|he|they)\s+do)\b", re.IGNORECASE),
+    re.compile(r"\b(is\s+(in\s+pain|hurting|suffering|getting\s+worse))\b", re.IGNORECASE),
+    re.compile(r"\b(says?\s+(she|he|they)\s+(can'?t|has|is|feels?))\b", re.IGNORECASE),
+]
+
+
+_POST_NEGATION_PATTERNS = [
+    re.compile(r"\b(free|resolved|gone|cleared|negative|ruled\s+out|improving|controlled|stable)\b", re.IGNORECASE),
+]
+
+
+def _check_negation_in_window(text: str, match_start: int, window_size: int = NEGATION_WINDOW_SIZE, match_end: int = 0) -> bool:
+    """
+    Check if there's a negation word within window_size words before the match,
+    OR a post-negation/resolution word immediately after the match.
+    
+    Args:
+        text: Full text to check
+        match_start: Character position where the safety keyword starts
+        window_size: Number of words to look back for negation
+        match_end: Character position where the safety keyword ends (for post-check)
+        
+    Returns:
+        True if negation found in window, False otherwise
+    """
+    # Get text before the match
+    text_before = text[:match_start].lower()
+    
+    # Split into words and get the last N words
+    words_before = text_before.split()
+    window_words = words_before[-window_size:] if len(words_before) >= window_size else words_before
+    window_text = " ".join(window_words)
+    
+    # Check for negation patterns in the window BEFORE the keyword
+    for neg_pattern in NEGATION_PATTERNS:
+        if neg_pattern.search(window_text):
+            return True
+
+    # Check for post-negation words AFTER the keyword (e.g., "seizure free")
+    if match_end > 0:
+        text_after = text[match_end:match_end + 30].lower().strip()
+        for post_pattern in _POST_NEGATION_PATTERNS:
+            if post_pattern.search(text_after):
+                return True
+    
+    return False
+
+
+def _check_historical_context(text: str, match_start: int) -> bool:
+    """
+    Check if the context suggests historical/third-party reference.
+    
+    Returns True (suppress escalation) ONLY if historical/proxy context is
+    found AND there are no active-urgency signals indicating the report is
+    about a current emergency. Proxy reports with acute symptoms (e.g.,
+    "my mother is having chest pain") are treated as authoritative.
+    
+    Args:
+        text: Full text to check
+        match_start: Character position where the safety keyword starts
+        
+    Returns:
+        True if historical/third-party context found WITHOUT active urgency,
+        False otherwise (i.e., DO escalate)
+    """
+    # Check the sentence or nearby text for historical patterns
+    # Get text around the match (100 chars before)
+    context_start = max(0, match_start - 100)
+    context_text = text[context_start:match_start].lower()
+    
+    has_historical = False
+    for pattern in HISTORICAL_PATTERNS:
+        if pattern.search(context_text):
+            has_historical = True
+            break
+    
+    if not has_historical:
+        return False
+    
+    # Historical/proxy pattern found — but check if there are active-urgency
+    # signals in the FULL text that indicate a current emergency.
+    # E.g., "my mother is having chest pain" should NOT be suppressed.
+    text_lower = text.lower()
+    for urgency_pattern in PROXY_ACTIVE_URGENCY_PATTERNS:
+        if urgency_pattern.search(text_lower):
+            logger.info(
+                "Historical/proxy context found but active-urgency signal "
+                "overrides suppression — treating as authoritative report"
+            )
+            return False
+    
+    return True
+
+
+def check_safety_keywords(text: str) -> Tuple[bool, Optional[str]]:
+    """
+    Check text for critical safety keywords with negation awareness.
+    
+    This is a rule-based safety net that triggers escalation regardless of
+    model predictions. Critical for patient safety in clinical settings.
+    
+    Negation-aware: Will NOT trigger on phrases like:
+    - "I'm not suicidal"
+    - "I don't have chest pain"
+    - "My friend had a heart attack last year"
+    
+    Returns:
+        Tuple of (should_escalate, matched_pattern_description)
+    """
+    text_lower = text.lower()
+    
+    for pattern, description, check_negation in SAFETY_ESCALATION_PATTERNS:
+        match = pattern.search(text_lower)
+        if match:
+            match_start = match.start()
+            
+            # Check for negation if required
+            if check_negation:
+                if _check_negation_in_window(text, match_start, match_end=match.end()):
+                    # Negation found - don't escalate but log for review
+                    logger.info(f"Safety keyword '{match.group()}' found but negated - not escalating")
+                    continue
+                
+                # Check for historical/third-party context
+                if _check_historical_context(text, match_start):
+                    logger.info(f"Safety keyword '{match.group()}' found in historical context - not escalating")
+                    continue
+            
+            # No negation or historical context - escalate
+            return True, f"safety_keyword_match: '{match.group()}' ({description})"
+    
+    return False, None
+
+
+def apply_decision_policy(
+    probabilities: np.ndarray,
+    argmax_label: str,
+    input_text: Optional[str] = None
+) -> Tuple[str, bool, str]:
+    """
+    Apply decision policy to determine final label and escalation status.
+    
+    Includes safety keyword fallback for critical patient safety.
+    
+    Returns:
+        Tuple of (final_label, should_escalate, decision_reason)
+    """
+    # SAFETY FIRST: Check for critical keywords before model decision
+    if input_text:
+        keyword_escalate, keyword_reason = check_safety_keywords(input_text)
+        if keyword_escalate:
+            escalation_label = decision_policy.get("escalation_policy", {}).get("escalation_label", "ESCALATION")
+            return escalation_label, True, f"SAFETY_OVERRIDE: {keyword_reason}"
+    
+    escalation_config = decision_policy.get("escalation_policy", {})
+    confidence_config = decision_policy.get("confidence_policy", {})
+    
+    escalation_label = escalation_config.get("escalation_label", "ESCALATION")
+    escalation_threshold = escalation_config.get("escalation_threshold", 0.5)
+    min_confidence = confidence_config.get("min_confidence", 0.3)
+    fallback_label = confidence_config.get("fallback_label", "OTHER")
+    
+    # Get escalation probability
+    escalation_id = label2id.get(escalation_label, 0)
+    escalation_prob = float(probabilities[escalation_id])
+    
+    # Get max probability (confidence)
+    max_prob = float(np.max(probabilities))
+    
+    # Apply decision logic
+    # Rule 1: If escalation probability exceeds threshold, always escalate
+    if escalation_prob >= escalation_threshold:
+        return escalation_label, True, f"P({escalation_label})={escalation_prob:.3f} >= threshold={escalation_threshold}"
+    
+    # Rule 2: If confidence is too low, route to fallback
+    if max_prob < min_confidence:
+        return fallback_label, False, f"Low confidence ({max_prob:.3f} < {min_confidence}), routing to {fallback_label}"
+    
+    # Rule 3: Use argmax prediction
+    return argmax_label, False, f"Standard prediction with confidence={max_prob:.3f}"
+
+
+def shutdown_cleanup() -> None:
+    """Clean up resources on shutdown."""
+    global inference_executor
+    if inference_executor:
+        logger.info("Shutting down inference thread pool...")
+        inference_executor.shutdown(wait=True, cancel_futures=False)
+        logger.info("Inference thread pool shut down")
+
+
+@asynccontextmanager
+async def lifespan(app: FastAPI):
+    """Lifespan context manager for startup and shutdown events."""
+    # Startup
+    try:
+        load_model()
+        logger.info("Service ready")
+    except Exception as e:
+        logger.error(f"Failed to load model: {e}")
+        raise
+    
+    yield  # Application runs here
+    
+    # Shutdown
+    shutdown_cleanup()
+    logger.info("Service shutdown complete")
+
+
+# Register lifespan with app
+app.router.lifespan_context = lifespan
+
+
+# Graceful shutdown signal handler
+def handle_shutdown_signal(signum, frame):
+    """Handle shutdown signals gracefully."""
+    logger.info(f"Received signal {signum}, initiating graceful shutdown...")
+    shutdown_cleanup()
+    sys.exit(0)
+
+
+# Register signal handlers (Unix-like systems)
+if hasattr(signal, 'SIGTERM'):
+    signal.signal(signal.SIGTERM, handle_shutdown_signal)
+if hasattr(signal, 'SIGINT'):
+    signal.signal(signal.SIGINT, handle_shutdown_signal)
+
+
+def run_inference_sync(input_ids: np.ndarray, attention_mask: np.ndarray, token_type_ids: Optional[np.ndarray]) -> np.ndarray:
+    """
+    Run ONNX inference synchronously (called from thread pool).
+    
+    This function is CPU-bound and should be run in a thread pool
+    to avoid blocking the async event loop.
+    """
+    ort_inputs = {
+        "input_ids": input_ids,
+        "attention_mask": attention_mask,
+    }
+    
+    # Add token_type_ids if model expects it
+    input_names = [inp.name for inp in session.get_inputs()]
+    if "token_type_ids" in input_names and token_type_ids is not None:
+        ort_inputs["token_type_ids"] = token_type_ids
+    
+    outputs = session.run(None, ort_inputs)
+    return outputs[0][0]  # Return logits for first sample
+
+
+async def run_inference_async(input_ids: np.ndarray, attention_mask: np.ndarray, token_type_ids: Optional[np.ndarray]) -> np.ndarray:
+    """
+    Run ONNX inference asynchronously using thread pool with timeout.
+    
+    This prevents blocking the async event loop during CPU-bound inference.
+    Raises asyncio.TimeoutError if inference takes longer than INFERENCE_TIMEOUT_SECONDS.
+    """
+    loop = asyncio.get_running_loop()
+    try:
+        return await asyncio.wait_for(
+            loop.run_in_executor(
+                inference_executor,
+                run_inference_sync,
+                input_ids,
+                attention_mask,
+                token_type_ids
+            ),
+            timeout=INFERENCE_TIMEOUT_SECONDS
+        )
+    except asyncio.TimeoutError:
+        logger.error(f"Inference timed out after {INFERENCE_TIMEOUT_SECONDS}s")
+        raise
+
+
+# Health check cache to prevent DoS via repeated inference
+_health_check_cache: Dict[str, Any] = {"status": None, "timestamp": 0.0}
+_health_check_cache_lock = threading.Lock()
+HEALTH_CHECK_CACHE_TTL = 5.0  # Cache health status for 5 seconds
+
+
+@app.get("/health", response_model=HealthResponse)
+@limiter.limit("30/minute")
+async def health_check(request: Request):
+    """Health check endpoint (no auth required for load balancer probes)."""
+    current_time = time.time()
+    
+    # Return cached result if within TTL to prevent DoS via repeated inference
+    with _health_check_cache_lock:
+        if (
+            _health_check_cache["status"] is not None
+            and current_time - _health_check_cache["timestamp"] < HEALTH_CHECK_CACHE_TTL
+        ):
+            cached = _health_check_cache["status"]
+            return HealthResponse(
+                status=cached["status"],
+                model_loaded=cached["model_loaded"],
+                policy_loaded=cached["policy_loaded"],
+                decision_engine_loaded=cached.get("decision_engine_loaded", False),
+                timestamp=datetime.now(timezone.utc).isoformat(),
+            )
+    
+    model_healthy = False
+    if session is not None and tokenizer is not None:
+        try:
+            # Quick validation that model can run inference
+            test_inputs = tokenizer("test", return_tensors="np", max_length=8, truncation=True, padding="max_length")
+            input_dict = {"input_ids": test_inputs["input_ids"], "attention_mask": test_inputs["attention_mask"]}
+            input_names = [inp.name for inp in session.get_inputs()]
+            if "token_type_ids" in input_names:
+                input_dict["token_type_ids"] = np.zeros_like(test_inputs["input_ids"])
+            session.run(None, input_dict)
+            model_healthy = True
+        except Exception:
+            model_healthy = False
+    
+    engine_loaded = DECISION_ENGINE_AVAILABLE and domain_nominator is not None
+    
+    # Cache the result (thread-safe)
+    with _health_check_cache_lock:
+        _health_check_cache["status"] = {
+            "status": "healthy" if model_healthy else "unhealthy",
+            "model_loaded": model_healthy,
+            "policy_loaded": bool(decision_policy),
+            "decision_engine_loaded": engine_loaded,
+        }
+        _health_check_cache["timestamp"] = current_time
+    
+    return HealthResponse(
+        status="healthy" if model_healthy else "unhealthy",
+        model_loaded=model_healthy,
+        policy_loaded=bool(decision_policy),
+        decision_engine_loaded=engine_loaded,
+        timestamp=datetime.now(timezone.utc).isoformat(),
+    )
+
+
+@app.post("/predict", response_model=PredictResponse)
+@limiter.limit(RATE_LIMIT)
+async def predict(
+    request: Request,
+    predict_request: PredictRequest,
+    api_key: str = Depends(verify_api_key),
+):
+    """
+    Classify medical intent from input text.
+    
+    Applies decision policy for escalation thresholding.
+    Requires API key authentication.
+    
+    Uses async inference to prevent blocking the event loop under load.
+    """
+    if session is None or tokenizer is None:
+        raise HTTPException(status_code=503, detail="Model not loaded")
+    
+    # Validate combined length
+    try:
+        predict_request.validate_combined_length()
+    except ValueError as e:
+        raise HTTPException(status_code=400, detail=str(e))
+    
+    total_start = time.perf_counter()
+    
+    # Prepare input text — run temporal preprocessor first
+    text = predict_request.text
+    temporal_signal = None
+    if TEMPORAL_PREPROCESSOR_AVAILABLE:
+        temporal_signal = preprocess_temporal(text, predict_request.context)
+        text = temporal_signal.processed_text
+    
+    # Tokenize (fast enough to run synchronously)
+    # When context is provided, use BERT's native text_pair so that:
+    #   1. Text (current utterance) is Segment A — always fully preserved
+    #   2. Context is Segment B — truncated first if combined length exceeds max_length
+    # truncation="only_second" ensures the patient's current text is NEVER truncated
+    tokenize_start = time.perf_counter()
+    if predict_request.context:
+        inputs = tokenizer(
+            text,
+            text_pair=predict_request.context,
+            padding="max_length",
+            truncation="only_second",
+            max_length=MAX_LENGTH,
+            return_tensors="np"
+        )
+    else:
+        inputs = tokenizer(
+            text,
+            padding="max_length",
+            truncation=True,
+            max_length=MAX_LENGTH,
+            return_tensors="np"
+        )
+    tokenize_time = (time.perf_counter() - tokenize_start) * 1000
+    
+    # Prepare ONNX inputs
+    input_ids = inputs["input_ids"].astype(np.int64)
+    attention_mask = inputs["attention_mask"].astype(np.int64)
+    
+    # Prepare token_type_ids if needed
+    token_type_ids = None
+    input_names = [inp.name for inp in session.get_inputs()]
+    if "token_type_ids" in input_names:
+        if "token_type_ids" in inputs:
+            token_type_ids = inputs["token_type_ids"].astype(np.int64)
+        else:
+            token_type_ids = np.zeros_like(input_ids, dtype=np.int64)
+    
+    # Run inference asynchronously (prevents blocking event loop)
+    inference_start = time.perf_counter()
+    logits = await run_inference_async(input_ids, attention_mask, token_type_ids)
+    inference_time = (time.perf_counter() - inference_start) * 1000
+    
+    # Postprocess
+    postprocess_start = time.perf_counter()
+    probabilities = softmax(logits)
+    
+    # Get argmax prediction
+    argmax_id = int(np.argmax(probabilities))
+    argmax_label = id2label.get(argmax_id, "UNKNOWN")
+    
+    # Apply decision policy (includes safety keyword fallback)
+    # Use original text (not context-concatenated) for safety keyword checks
+    # to avoid false escalation from keywords in historical context
+    final_label, should_escalate, decision_reason = apply_decision_policy(
+        probabilities, argmax_label, input_text=predict_request.text
+    )
+    
+    # Temporal preprocessor override: if preprocessor detected active emergency
+    # but model/policy didn't escalate, force escalation (safety net)
+    if temporal_signal and temporal_signal.is_active_emergency and not should_escalate:
+        escalation_label_name = decision_policy.get("escalation_policy", {}).get("escalation_label", "ESCALATION")
+        final_label = escalation_label_name
+        should_escalate = True
+        decision_reason = f"TEMPORAL_OVERRIDE: {temporal_signal.reason}"
+    
+    # Build probability dict
+    prob_dict = {
+        id2label.get(i, f"LABEL_{i}"): float(p)
+        for i, p in enumerate(probabilities)
+    }
+    
+    # Get escalation probability
+    escalation_label = decision_policy.get("escalation_policy", {}).get("escalation_label", "ESCALATION")
+    escalation_prob = prob_dict.get(escalation_label, 0.0)
+    
+    postprocess_time = (time.perf_counter() - postprocess_start) * 1000
+    total_time = (time.perf_counter() - total_start) * 1000
+    
+    # Record metrics
+    if ENABLE_METRICS:
+        metrics.record_request(
+            success=True,
+            inference_ms=inference_time,
+            tokenize_ms=tokenize_time,
+            escalated=should_escalate
+        )
+    
+    # Taxonomy scoring (deterministic)
+    tax_scores: Dict[str, float] = {}
+    matched_tax: List[TaxonomyMatchDetail] = []
+    top_tax_domain: Optional[str] = None
+    if TAXONOMY_SCORER_AVAILABLE and trigger_engine and decision_config:
+        try:
+            tax_result = score_taxonomy(predict_request.text, trigger_engine, decision_config)
+            tax_scores = tax_result.scores
+            top_tax_domain = tax_result.top_domain
+            matched_tax = [
+                TaxonomyMatchDetail(
+                    domain=d.domain,
+                    score=round(d.score, 4),
+                    confidence_tier=d.confidence_tier,
+                    priority=d.priority,
+                    is_negated=d.is_negated,
+                    target_risk_class=d.target_risk_class,
+                    recommended_flow=d.recommended_flow,
+                    trigger_count=d.trigger_count,
+                    matched_phrases=d.matched_phrases,
+                )
+                for d in tax_result.matched_domains
+            ]
+
+            # SAFETY NET: If any matched taxonomy domain is a hard-escalate
+            # R3 domain (not negated), force escalation even when ML disagrees.
+            # For temporally resolved cases: still escalate but note follow-up
+            # (past R3 symptoms warrant clinical assessment, not suppression).
+            is_temporally_resolved = (
+                temporal_signal
+                and temporal_signal.temporal_tag == "resolved"
+            )
+            if decision_config:
+                hard_esc_domains = decision_config.hard_escalate_domains
+                for d in tax_result.matched_domains:
+                    if d.domain in hard_esc_domains and not d.is_negated and d.score > 0:
+                        if not should_escalate:
+                            escalation_label_name = decision_policy.get(
+                                "escalation_policy", {}
+                            ).get("escalation_label", "ESCALATION")
+                            final_label = escalation_label_name
+                            should_escalate = True
+                            if is_temporally_resolved:
+                                decision_reason = (
+                                    f"TAXONOMY_FOLLOW_UP: {d.domain} "
+                                    f"(resolved but R3 domain warrants clinical follow-up)"
+                                )
+                            else:
+                                decision_reason = (
+                                    f"TAXONOMY_ESCALATION: {d.domain} "
+                                    f"(target_risk={d.target_risk_class}, "
+                                    f"confidence={d.confidence_tier})"
+                                )
+                            logger.warning(
+                                "Taxonomy safety override on /predict: "
+                                "domain=%s risk=%s ML_label=%s temporal=%s",
+                                d.domain, d.target_risk_class, argmax_label,
+                                "resolved" if is_temporally_resolved else "active",
+                            )
+                        break
+        except Exception as e:
+            logger.warning("Taxonomy scoring failed: %s", e)
+
+    return PredictResponse(
+        predicted_label=final_label,
+        probabilities=prob_dict,
+        taxonomy_scores=tax_scores,
+        matched_taxonomy=matched_tax,
+        top_taxonomy_domain=top_tax_domain,
+        should_escalate=should_escalate,
+        escalation_probability=escalation_prob,
+        confidence=float(np.max(probabilities)),
+        decision_reason=decision_reason,
+        timing=TimingInfo(
+            tokenize_ms=round(tokenize_time, 3),
+            inference_ms=round(inference_time, 3),
+            postprocess_ms=round(postprocess_time, 3),
+            total_ms=round(total_time, 3),
+        ),
+    )
+
+
+@app.post("/predict/clinical", response_model=ClinicalAssessmentResponse, tags=["Clinical"])
+@limiter.limit(RATE_LIMIT)
+async def predict_clinical(
+    request: Request,
+    predict_request: PredictRequest,
+    api_key: str = Depends(verify_api_key),
+):
+    """
+    Clinical risk assessment endpoint.
+
+    Combines DriveHealthBERT ML classification with taxonomy-based domain nomination
+    and 4-tier risk classification (R0/R1/R2/R3).
+
+    Returns the full clinical assessment including:
+    - ML predicted label and probabilities
+    - Primary clinical domain (e.g., chest_pain, suicidal_ideation)
+    - Risk class: R0 (no concern) → R3 (call 911)
+    - Domain nominations ranked by acuity
+    - Recommended conversation flow
+    - Safety override and hard-escalate flags
+    """
+    if session is None or tokenizer is None:
+        raise HTTPException(status_code=503, detail="Model not loaded")
+    if not DECISION_ENGINE_AVAILABLE or domain_nominator is None:
+        raise HTTPException(
+            status_code=503,
+            detail="Decision engine not loaded. Ensure decision/ config directory exists.",
+        )
+
+    try:
+        predict_request.validate_combined_length()
+    except ValueError as e:
+        raise HTTPException(status_code=400, detail=str(e))
+
+    total_start = time.perf_counter()
+
+    # Prepare input text — run temporal preprocessor first
+    text = predict_request.text
+    temporal_signal = None
+    if TEMPORAL_PREPROCESSOR_AVAILABLE:
+        temporal_signal = preprocess_temporal(text, predict_request.context)
+        text = temporal_signal.processed_text
+
+    # Tokenize: text as Segment A (never truncated), context as Segment B (truncated first)
+    tokenize_start = time.perf_counter()
+    if predict_request.context:
+        inputs = tokenizer(
+            text,
+            text_pair=predict_request.context,
+            padding="max_length",
+            truncation="only_second",
+            max_length=MAX_LENGTH,
+            return_tensors="np",
+        )
+    else:
+        inputs = tokenizer(
+            text,
+            padding="max_length",
+            truncation=True,
+            max_length=MAX_LENGTH,
+            return_tensors="np",
+        )
+    tokenize_time = (time.perf_counter() - tokenize_start) * 1000
+
+    # Prepare ONNX inputs
+    input_ids = inputs["input_ids"].astype(np.int64)
+    attention_mask = inputs["attention_mask"].astype(np.int64)
+    token_type_ids = None
+    input_names = [inp.name for inp in session.get_inputs()]
+    if "token_type_ids" in input_names:
+        if "token_type_ids" in inputs:
+            token_type_ids = inputs["token_type_ids"].astype(np.int64)
+        else:
+            token_type_ids = np.zeros_like(input_ids, dtype=np.int64)
+
+    # Run ML inference
+    inference_start = time.perf_counter()
+    logits = await run_inference_async(input_ids, attention_mask, token_type_ids)
+    inference_time = (time.perf_counter() - inference_start) * 1000
+
+    # Postprocess ML output
+    postprocess_start = time.perf_counter()
+    probabilities = softmax(logits)
+    argmax_id = int(np.argmax(probabilities))
+    argmax_label = id2label.get(argmax_id, "UNKNOWN")
+    ml_confidence = float(np.max(probabilities))
+
+    prob_dict = {
+        id2label.get(i, f"LABEL_{i}"): float(p)
+        for i, p in enumerate(probabilities)
+    }
+
+    escalation_label = decision_policy.get("escalation_policy", {}).get(
+        "escalation_label", "ESCALATION"
+    )
+    escalation_prob = prob_dict.get(escalation_label, 0.0)
+
+    # Run Decision Engine — use ORIGINAL text (not context-concatenated)
+    nominations = domain_nominator.nominate(
+        text=predict_request.text,
+        ml_label=argmax_label,
+        ml_probabilities=prob_dict,
+    )
+    assessment = risk_classifier.assess(
+        nominations=nominations,
+        slot_values={},  # Phase 2: filled by flow engine
+        patient_context=None,  # Phase 3: filled by FHIR loader
+        ml_label=argmax_label,
+        ml_confidence=ml_confidence,
+    )
+
+    # Determine final label and escalation (merging ML + decision engine)
+    if assessment.risk_class >= RiskClass.R2:
+        should_escalate = True
+        final_label = escalation_label
+        if assessment.hard_escalate:
+            decision_reason = f"HARD_ESCALATE: {assessment.primary_domain} → {assessment.risk_class.value}"
+        elif assessment.safety_override:
+            decision_reason = f"SAFETY_OVERRIDE: {assessment.primary_domain} → {assessment.risk_class.value}"
+        else:
+            decision_reason = (
+                f"CLINICAL_RISK: {assessment.primary_domain} → "
+                f"{assessment.risk_class.value} (ML={argmax_label} {ml_confidence:.3f})"
+            )
+    else:
+        # Use legacy decision policy for non-escalation
+        final_label, should_escalate, decision_reason = apply_decision_policy(
+            probabilities, argmax_label, input_text=predict_request.text
+        )
+        # Belt + suspenders: if legacy policy escalated but engine says R0/R1,
+        # upgrade risk_class to R2 minimum. Never suppress an escalation.
+        if should_escalate and assessment.risk_class < RiskClass.R2:
+            assessment = RiskAssessment(
+                risk_class=RiskClass.R2,
+                primary_domain=assessment.primary_domain,
+                domain_nominations=assessment.domain_nominations,
+                matched_rules=assessment.matched_rules,
+                suppressions=assessment.suppressions,
+                hard_escalate=assessment.hard_escalate,
+                safety_override=True,
+                ml_label=assessment.ml_label,
+                ml_confidence=assessment.ml_confidence,
+                recommended_flow="handoff",
+                recommended_action=assessment.recommended_action,
+            )
+
+    # Temporal preprocessor override for /predict/clinical
+    if temporal_signal and temporal_signal.is_active_emergency and not should_escalate:
+        should_escalate = True
+        final_label = escalation_label
+        decision_reason = f"TEMPORAL_OVERRIDE: {temporal_signal.reason}"
+        if assessment.risk_class < RiskClass.R2:
+            assessment = RiskAssessment(
+                risk_class=RiskClass.R2,
+                primary_domain=assessment.primary_domain,
+                domain_nominations=assessment.domain_nominations,
+                matched_rules=assessment.matched_rules,
+                suppressions=assessment.suppressions,
+                hard_escalate=assessment.hard_escalate,
+                safety_override=True,
+                ml_label=assessment.ml_label,
+                ml_confidence=assessment.ml_confidence,
+                recommended_flow="handoff",
+                recommended_action=assessment.recommended_action,
+            )
+
+    # CONTRASTIVE REVERSAL OVERRIDE: When temporal preprocessor detects a
+    # BUT-clause reversal (e.g., "chest pain went away but it's back"), the
+    # domain nomination may have negated the R3 domain (e.g., "chest pain went
+    # away" matches negation patterns). Override negation for R3 domains when
+    # temporal analysis confirms the condition is currently active.
+    if (
+        temporal_signal
+        and temporal_signal.is_active_emergency
+        and any(
+            r.startswith("but_clause_reversal") or r == "contrastive_post_active"
+            for r in temporal_signal.matched_rules
+        )
+        and assessment.risk_class < RiskClass.R3
+    ):
+        # Check if any R3 domain was nominated but negated
+        override_domain = None
+        if decision_config:
+            hard_esc_domains = decision_config.hard_escalate_domains
+            for nom in nominations:
+                if nom.domain in hard_esc_domains and nom.is_negated:
+                    override_domain = nom.domain
+                    break
+        if override_domain:
+            should_escalate = True
+            final_label = escalation_label
+            decision_reason = (
+                f"CONTRASTIVE_OVERRIDE: {override_domain} was negated but "
+                f"BUT-clause reversal confirms active condition — R3"
+            )
+            assessment = RiskAssessment(
+                risk_class=RiskClass.R3,
+                primary_domain=override_domain,
+                domain_nominations=assessment.domain_nominations,
+                matched_rules=assessment.matched_rules,
+                suppressions=assessment.suppressions,
+                hard_escalate=True,
+                safety_override=True,
+                ml_label=assessment.ml_label,
+                ml_confidence=assessment.ml_confidence,
+                recommended_flow="escalate_r3",
+                recommended_action=None,
+            )
+            logger.warning(
+                "Contrastive reversal override: %s negation overridden, "
+                "temporal confirms active — R3",
+                override_domain,
+            )
+
+    # Temporal DE-ESCALATION: If the temporal preprocessor detected a clearly
+    # resolved / past condition AND the escalation came from taxonomy hard-escalate,
+    # downgrade from R3 to R2 (clinical follow-up), NOT to R1.
+    #
+    # SAFETY RATIONALE: Even resolved R3 symptoms warrant clinical follow-up.
+    # "I had chest pain yesterday but I'm fine" is STILL a cardiac red flag.
+    # R2 = warm transfer to nurse for clinical assessment. R1 would suppress.
+    # Proxy reports are treated as authoritative — caregivers speak for patients.
+    if (
+        temporal_signal
+        and temporal_signal.temporal_tag == "resolved"
+        and should_escalate
+        and assessment.hard_escalate
+    ):
+        # Downgrade to R2 (clinical follow-up), keep should_escalate=True
+        decision_reason = (
+            f"TEMPORAL_FOLLOW_UP: {assessment.primary_domain} detected, "
+            f"condition appears resolved ({temporal_signal.reason}) "
+            f"— downgraded to R2 clinical follow-up"
+        )
+        assessment = RiskAssessment(
+            risk_class=RiskClass.R2,
+            primary_domain=assessment.primary_domain,
+            domain_nominations=assessment.domain_nominations,
+            matched_rules=assessment.matched_rules,
+            suppressions=assessment.suppressions,
+            hard_escalate=False,
+            safety_override=True,
+            ml_label=assessment.ml_label,
+            ml_confidence=assessment.ml_confidence,
+            recommended_flow="clinical_follow_up",
+            recommended_action="Warm transfer to nurse — past R3 symptom warrants clinical assessment",
+        )
+        logger.info(
+            "Temporal de-escalation: %s resolved, downgrading from R3 to R2 (clinical follow-up)",
+            assessment.primary_domain,
+        )
+
+    # Build risk description
+    risk_descriptions = {
+        "R0": "No clinical concern identified",
+        "R1": "Low-level concern, routine follow-up",
+        "R2": "Moderate concern, warm transfer to nurse",
+        "R3": "Emergent — instruct patient to call 911 and transfer to nurse",
+    }
+
+    # Build domain nomination responses
+    nom_responses = [
+        DomainNominationResponse(
+            domain=n.domain,
+            confidence_tier=n.confidence_tier.value,
+            priority=n.priority,
+            target_risk_class=n.target_risk_class.value if n.target_risk_class else None,
+            is_negated=n.is_negated,
+            recommended_flow=n.recommended_flow,
+            trigger_match_count=len(n.trigger_matches),
+        )
+        for n in nominations[:10]  # Cap at 10 for response size
+    ]
+
+    postprocess_time = (time.perf_counter() - postprocess_start) * 1000
+    total_time = (time.perf_counter() - total_start) * 1000
+
+    if ENABLE_METRICS:
+        metrics.record_request(
+            success=True,
+            inference_ms=inference_time,
+            tokenize_ms=tokenize_time,
+            escalated=should_escalate,
+        )
+
+    # Audit log for clinical assessments
+    if assessment.risk_class >= RiskClass.R2:
+        audit_logger.warning(
+            "CLINICAL_ESCALATION: risk=%s domain=%s hard_escalate=%s safety_override=%s",
+            assessment.risk_class.value,
+            assessment.primary_domain,
+            assessment.hard_escalate,
+            assessment.safety_override,
+        )
+
+    # Taxonomy scoring (deterministic)
+    tax_scores: Dict[str, float] = {}
+    matched_tax: List[TaxonomyMatchDetail] = []
+    top_tax_domain: Optional[str] = None
+    if TAXONOMY_SCORER_AVAILABLE and trigger_engine and decision_config:
+        try:
+            tax_result = score_taxonomy(predict_request.text, trigger_engine, decision_config)
+            tax_scores = tax_result.scores
+            top_tax_domain = tax_result.top_domain
+            matched_tax = [
+                TaxonomyMatchDetail(
+                    domain=d.domain,
+                    score=round(d.score, 4),
+                    confidence_tier=d.confidence_tier,
+                    priority=d.priority,
+                    is_negated=d.is_negated,
+                    target_risk_class=d.target_risk_class,
+                    recommended_flow=d.recommended_flow,
+                    trigger_count=d.trigger_count,
+                    matched_phrases=d.matched_phrases,
+                )
+                for d in tax_result.matched_domains
+            ]
+        except Exception as e:
+            logger.warning("Taxonomy scoring failed in /predict/clinical: %s", e)
+
+    return ClinicalAssessmentResponse(
+        predicted_label=final_label,
+        probabilities=prob_dict,
+        ml_confidence=ml_confidence,
+        risk_class=assessment.risk_class.value,
+        risk_description=risk_descriptions.get(
+            assessment.risk_class.value, "Unknown"
+        ),
+        primary_domain=assessment.primary_domain,
+        requires_911=assessment.requires_911,
+        requires_nurse_transfer=assessment.requires_nurse_transfer,
+        hard_escalate=assessment.hard_escalate,
+        safety_override=assessment.safety_override,
+        domain_nominations=nom_responses,
+        taxonomy_scores=tax_scores,
+        matched_taxonomy=matched_tax,
+        top_taxonomy_domain=top_tax_domain,
+        recommended_flow=assessment.recommended_flow,
+        recommended_action=(
+            assessment.recommended_action.value
+            if assessment.recommended_action and hasattr(assessment.recommended_action, 'value')
+            else assessment.recommended_action
+        ),
+        should_escalate=should_escalate,
+        escalation_probability=escalation_prob,
+        decision_reason=decision_reason,
+        timing=TimingInfo(
+            tokenize_ms=round(tokenize_time, 3),
+            inference_ms=round(inference_time, 3),
+            postprocess_ms=round(postprocess_time, 3),
+            total_ms=round(total_time, 3),
+        ),
+    )
+
+
+# =============================================================================
+# PHASE 2: CONVERSATION FLOW ENDPOINTS
+# =============================================================================
+
+class ConversationStartRequest(BaseModel):
+    """Request to start a new conversation session."""
+    session_id: str = Field(..., min_length=1, max_length=128, description="Unique session identifier")
+    patient_id: Optional[str] = Field(None, description="Patient identifier")
+    tenant_id: Optional[str] = Field(None, description="Tenant identifier")
+
+
+class ConversationTurnRequest(BaseModel):
+    """Request to process a conversational turn."""
+    session_id: str = Field(..., min_length=1, max_length=128)
+    text: str = Field(..., min_length=1, max_length=MAX_INPUT_CHARS, description="Patient utterance")
+    extracted_slots: Optional[Dict[str, Any]] = Field(None, description="Slots extracted by NLU")
+
+    @field_validator("text", mode="before")
+    @classmethod
+    def sanitize_text(cls, v: Optional[str]) -> Optional[str]:
+        if v is None:
+            return None
+        v = bleach.clean(v, tags=[], strip=True)
+        v = " ".join(v.split())
+        v = v.replace("\x00", "").replace("\r", "")
+        return v
+
+
+class ResponseSpecResponse(BaseModel):
+    """LLM response constraints for a flow step."""
+    id: str = ""
+    goal: str = ""
+    tone: str = "professional"
+    must_include: List[str] = Field(default_factory=list)
+    must_ask: List[str] = Field(default_factory=list)
+    must_not: List[str] = Field(default_factory=list)
+    max_questions: int = 0
+
+
+class ConversationTurnResponse(BaseModel):
+    """Response from a conversation turn."""
+    outcome: str = Field(..., description="proceed / clarify / escalate / handoff / end")
+    flow_id: Optional[str] = None
+    flow_type: Optional[str] = None
+    step_number: int = 0
+    step_type: Optional[str] = None
+    response_spec: Optional[ResponseSpecResponse] = None
+    prompt_constraints: Optional[str] = Field(None, description="Ready-to-use LLM prompt constraints")
+    collects: List[str] = Field(default_factory=list)
+    handoff_target: Optional[str] = None
+    handoff_urgency: Optional[str] = None
+    risk_class: Optional[str] = None
+    domain: Optional[str] = None
+    message: str = ""
+    requires_reassessment: bool = False
+    # Clinical assessment included when available
+    clinical_assessment: Optional[Dict[str, Any]] = None
+    timing: Optional[TimingInfo] = None
+
+
+@app.post("/conversation/start", response_model=ConversationTurnResponse, tags=["Conversation"])
+@limiter.limit(RATE_LIMIT)
+async def conversation_start(
+    request: Request,
+    start_request: ConversationStartRequest,
+    api_key: str = Depends(verify_api_key),
+):
+    """
+    Start a new conversation session.
+
+    Creates a session and returns the first flow step (greeting).
+    The response_spec contains LLM constraints for generating Avery's response.
+    """
+    if not DECISION_ENGINE_AVAILABLE or flow_engine is None:
+        raise HTTPException(status_code=503, detail="Flow engine not loaded")
+
+    total_start = time.perf_counter()
+
+    session_state = flow_engine.create_session(
+        session_id=start_request.session_id,
+        patient_id=start_request.patient_id,
+        tenant_id=start_request.tenant_id,
+    )
+    result = flow_engine.start_call(session_state)
+
+    total_time = (time.perf_counter() - total_start) * 1000
+
+    return _turn_result_to_response(result, total_time)
+
+
+@app.post("/conversation/turn", response_model=ConversationTurnResponse, tags=["Conversation"])
+@limiter.limit(RATE_LIMIT)
+async def conversation_turn(
+    request: Request,
+    turn_request: ConversationTurnRequest,
+    api_key: str = Depends(verify_api_key),
+):
+    """
+    Process a patient turn in an active conversation.
+
+    Runs ML inference + taxonomy triggers + risk assessment, then advances
+    the conversation flow. Returns the next response_spec for LLM generation.
+
+    Safety behavior:
+    - R3 emergencies interrupt any active flow immediately
+    - Hard-escalate domains (suicidal_ideation, homicidal_ideation) always escalate
+    - Response specs enforce must_not constraints (e.g., never say "heart attack")
+    """
+    if session is None or tokenizer is None:
+        raise HTTPException(status_code=503, detail="Model not loaded")
+    if not DECISION_ENGINE_AVAILABLE or flow_engine is None:
+        raise HTTPException(status_code=503, detail="Flow engine not loaded")
+
+    session_state = flow_engine.get_session(turn_request.session_id)
+    if session_state is None:
+        raise HTTPException(status_code=404, detail=f"Session '{turn_request.session_id}' not found")
+
+    total_start = time.perf_counter()
+
+    # Temporal preprocessor + safety keyword check (safety net for /conversation/turn)
+    temporal_signal = None
+    text_for_model = turn_request.text
+    if TEMPORAL_PREPROCESSOR_AVAILABLE:
+        temporal_signal = preprocess_temporal(turn_request.text)
+        text_for_model = temporal_signal.processed_text
+
+    # Step 1: ML inference on patient text
+    tokenize_start = time.perf_counter()
+    inputs = tokenizer(
+        text_for_model,
+        padding="max_length",
+        truncation=True,
+        max_length=MAX_LENGTH,
+        return_tensors="np",
+    )
+    tokenize_time = (time.perf_counter() - tokenize_start) * 1000
+
+    input_ids = inputs["input_ids"].astype(np.int64)
+    attention_mask = inputs["attention_mask"].astype(np.int64)
+    token_type_ids = None
+    input_names_list = [inp.name for inp in session.get_inputs()]
+    if "token_type_ids" in input_names_list:
+        if "token_type_ids" in inputs:
+            token_type_ids = inputs["token_type_ids"].astype(np.int64)
+        else:
+            token_type_ids = np.zeros_like(input_ids, dtype=np.int64)
+
+    inference_start = time.perf_counter()
+    logits = await run_inference_async(input_ids, attention_mask, token_type_ids)
+    inference_time = (time.perf_counter() - inference_start) * 1000
+
+    probabilities = softmax(logits)
+    argmax_id = int(np.argmax(probabilities))
+    argmax_label = id2label.get(argmax_id, "UNKNOWN")
+    ml_confidence = float(np.max(probabilities))
+
+    prob_dict = {
+        id2label.get(i, f"LABEL_{i}"): float(p)
+        for i, p in enumerate(probabilities)
+    }
+
+    # Step 2: Domain nomination + risk assessment
+    postprocess_start = time.perf_counter()
+    nominations = domain_nominator.nominate(
+        text=turn_request.text,
+        ml_label=argmax_label,
+        ml_probabilities=prob_dict,
+    )
+    assessment = risk_classifier.assess(
+        nominations=nominations,
+        slot_values=dict(session_state.slots.slots),
+        patient_context=None,
+        ml_label=argmax_label,
+        ml_confidence=ml_confidence,
+    )
+
+    # Safety keyword check (was missing from /conversation/turn — CRIT-13 fix)
+    keyword_escalate, keyword_reason = check_safety_keywords(turn_request.text)
+    if keyword_escalate and assessment.risk_class < RiskClass.R2:
+        assessment = RiskAssessment(
+            risk_class=RiskClass.R2,
+            primary_domain=assessment.primary_domain,
+            domain_nominations=assessment.domain_nominations,
+            matched_rules=assessment.matched_rules,
+            suppressions=assessment.suppressions,
+            hard_escalate=assessment.hard_escalate,
+            safety_override=True,
+            ml_label=assessment.ml_label,
+            ml_confidence=assessment.ml_confidence,
+            recommended_flow="handoff",
+            recommended_action=assessment.recommended_action,
+        )
+
+    # Temporal preprocessor override
+    if temporal_signal and temporal_signal.is_active_emergency and assessment.risk_class < RiskClass.R2:
+        assessment = RiskAssessment(
+            risk_class=RiskClass.R2,
+            primary_domain=assessment.primary_domain,
+            domain_nominations=assessment.domain_nominations,
+            matched_rules=assessment.matched_rules,
+            suppressions=assessment.suppressions,
+            hard_escalate=assessment.hard_escalate,
+            safety_override=True,
+            ml_label=assessment.ml_label,
+            ml_confidence=assessment.ml_confidence,
+            recommended_flow="handoff",
+            recommended_action=assessment.recommended_action,
+        )
+
+    # CONTRASTIVE REVERSAL OVERRIDE (mirrors /predict/clinical logic):
+    # When temporal BUT-clause reversal confirms active condition, override
+    # domain negation for R3 domains and force R3 escalation.
+    if (
+        temporal_signal
+        and temporal_signal.is_active_emergency
+        and any(
+            r.startswith("but_clause_reversal") or r == "contrastive_post_active"
+            for r in temporal_signal.matched_rules
+        )
+        and assessment.risk_class < RiskClass.R3
+    ):
+        override_domain = None
+        if decision_config:
+            hard_esc_domains = decision_config.hard_escalate_domains
+            for nom in nominations:
+                if nom.domain in hard_esc_domains and nom.is_negated:
+                    override_domain = nom.domain
+                    break
+        if override_domain:
+            assessment = RiskAssessment(
+                risk_class=RiskClass.R3,
+                primary_domain=override_domain,
+                domain_nominations=assessment.domain_nominations,
+                matched_rules=assessment.matched_rules,
+                suppressions=assessment.suppressions,
+                hard_escalate=True,
+                safety_override=True,
+                ml_label=assessment.ml_label,
+                ml_confidence=assessment.ml_confidence,
+                recommended_flow="escalate_r3",
+                recommended_action=None,
+            )
+            logger.warning(
+                "Contrastive reversal override (/conversation/turn): "
+                "%s negation overridden, temporal confirms active — R3",
+                override_domain,
+            )
+
+    # Step 3: Process turn through flow engine
+    result = flow_engine.process_turn(
+        session=session_state,
+        patient_text=turn_request.text,
+        assessment=assessment,
+        extracted_slots=turn_request.extracted_slots,
+    )
+
+    postprocess_time = (time.perf_counter() - postprocess_start) * 1000
+    total_time = (time.perf_counter() - total_start) * 1000
+
+    if ENABLE_METRICS:
+        metrics.record_request(
+            success=True,
+            inference_ms=inference_time,
+            tokenize_ms=tokenize_time,
+            escalated=result.is_escalation,
+        )
+
+    if result.is_escalation:
+        audit_logger.warning(
+            "CONVERSATION_ESCALATION: session=%s domain=%s risk=%s",
+            turn_request.session_id,
+            result.domain,
+            result.risk_class.value if result.risk_class else "unknown",
+        )
+
+    response = _turn_result_to_response(
+        result, total_time, tokenize_time, inference_time, postprocess_time
+    )
+    response.clinical_assessment = assessment.to_dict()
+    return response
+
+
+@app.post("/conversation/end", tags=["Conversation"])
+@limiter.limit(RATE_LIMIT)
+async def conversation_end(
+    request: Request,
+    session_id: str = Query(..., min_length=1),
+    api_key: str = Depends(verify_api_key),
+):
+    """End and clean up a conversation session."""
+    if flow_engine is None:
+        raise HTTPException(status_code=503, detail="Flow engine not loaded")
+    flow_engine.destroy_session(session_id)
+    return {"status": "ended", "session_id": session_id}
+
+
+def _turn_result_to_response(
+    result,
+    total_ms: float,
+    tokenize_ms: float = 0.0,
+    inference_ms: float = 0.0,
+    postprocess_ms: float = 0.0,
+) -> ConversationTurnResponse:
+    """Convert a TurnResult to a ConversationTurnResponse."""
+    spec_response = None
+    if result.response_spec:
+        spec_response = ResponseSpecResponse(
+            id=result.response_spec.spec_id,
+            goal=result.response_spec.goal,
+            tone=result.response_spec.tone,
+            must_include=result.response_spec.must_include,
+            must_ask=result.response_spec.must_ask,
+            must_not=result.response_spec.must_not,
+            max_questions=result.response_spec.max_questions,
+        )
+
+    return ConversationTurnResponse(
+        outcome=result.outcome.value,
+        flow_id=result.flow_id,
+        flow_type=result.flow_type,
+        step_number=result.step_number,
+        step_type=result.step_type,
+        response_spec=spec_response,
+        prompt_constraints=result.prompt_constraints,
+        collects=result.collects,
+        handoff_target=result.handoff_target,
+        handoff_urgency=result.handoff_urgency,
+        risk_class=result.risk_class.value if result.risk_class else None,
+        domain=result.domain,
+        message=result.message,
+        requires_reassessment=result.requires_reassessment,
+        timing=TimingInfo(
+            tokenize_ms=round(tokenize_ms, 3),
+            inference_ms=round(inference_ms, 3),
+            postprocess_ms=round(postprocess_ms, 3),
+            total_ms=round(total_ms, 3),
+        ),
+    )
+
+
+class MultiIntentResponse(BaseModel):
+    """Response for multi-intent detection."""
+    detected_intents: List[dict] = Field(..., description="List of detected intents with probabilities")
+    primary_intent: str = Field(..., description="Highest probability intent")
+    should_escalate: bool = Field(..., description="Whether escalation is needed")
+    taxonomy_scores: Dict[str, float] = Field(default_factory=dict, description="Deterministic match scores for all taxonomy domains")
+    matched_taxonomy: List[TaxonomyMatchDetail] = Field(default_factory=list, description="Taxonomy domains that matched with details")
+    top_taxonomy_domain: Optional[str] = Field(None, description="Highest-scoring taxonomy domain")
+    timing: TimingInfo
+
+
+def split_sentences(text: str) -> List[str]:
+    """
+    Split text into sentences for multi-intent detection.
+    
+    Handles:
+    - Standard punctuation (. ! ?)
+    - Conjunctions (and, but, also, plus)
+    - Semicolons and commas with conjunctions
+    - "I also need", "I also want" patterns
+    
+    Args:
+        text: Input text to split
+        
+    Returns:
+        List of sentence fragments for individual classification
+    """
+    # First, split on standard sentence terminators
+    parts = re.split(r'[.!?;]', text)
+    
+    # Further split on conjunctions that indicate separate intents
+    expanded_parts = []
+    conjunction_pattern = re.compile(
+        r'\s+(?:but|and also|also|plus|additionally|as well as)\s+',
+        re.IGNORECASE
+    )
+    # Pattern for "and I" which often indicates a new intent
+    and_i_pattern = re.compile(r'\s+and\s+(?=I\s)', re.IGNORECASE)
+    # Pattern for comma followed by "I need/want/have"
+    comma_i_pattern = re.compile(r',\s*(?=I\s+(?:need|want|have|also))', re.IGNORECASE)
+    
+    for part in parts:
+        # Split on conjunctions
+        sub_parts = conjunction_pattern.split(part)
+        for sub in sub_parts:
+            # Split on "and I"
+            sub_sub = and_i_pattern.split(sub)
+            for s in sub_sub:
+                # Split on ", I need/want"
+                final_parts = comma_i_pattern.split(s)
+                expanded_parts.extend(final_parts)
+    
+    # Clean and filter - minimum 5 chars to catch short phrases
+    cleaned = [p.strip() for p in expanded_parts if p and len(p.strip()) >= 5]
+    return cleaned if cleaned else [text]
+
+
+@app.post("/predict/multi", response_model=MultiIntentResponse)
+@limiter.limit(RATE_LIMIT)
+async def predict_multi_intent(
+    request: Request,
+    predict_request: PredictRequest,
+    threshold: float = Query(default=0.5, ge=0.0, le=1.0, description="Minimum probability threshold (0.0-1.0)"),
+    api_key: str = Depends(verify_api_key),
+):
+    """
+    Detect multiple intents by splitting compound sentences.
+    
+    Splits text on periods, 'but', 'and' conjunctions, then classifies each part.
+    Returns unique intents detected across all parts.
+    
+    Args:
+        threshold: Minimum probability to include an intent (default 0.5 = 50%, range 0.0-1.0)
+    """
+    # Validate threshold bounds
+    if not 0.0 <= threshold <= 1.0:
+        raise HTTPException(status_code=400, detail="threshold must be between 0.0 and 1.0")
+    
+    if session is None or tokenizer is None:
+        raise HTTPException(status_code=503, detail="Model not loaded")
+    
+    total_start = time.perf_counter()
+    
+    text = predict_request.text
+    context = predict_request.context
+    
+    # Temporal preprocessor
+    temporal_signal = None
+    if TEMPORAL_PREPROCESSOR_AVAILABLE:
+        temporal_signal = preprocess_temporal(text, context)
+        text = temporal_signal.processed_text
+    
+    # SAFETY FIRST: Check for critical keywords in original text only
+    # (not context-concatenated text, to avoid false escalation from historical context)
+    escalation_label = decision_policy.get("escalation_policy", {}).get("escalation_label", "ESCALATION")
+    escalation_threshold = decision_policy.get("escalation_policy", {}).get("escalation_threshold", 0.5)
+    
+    keyword_escalate, keyword_reason = check_safety_keywords(predict_request.text)
+    if keyword_escalate:
+        # Immediate escalation - don't even bother with full analysis
+        total_time = (time.perf_counter() - total_start) * 1000
+        # Taxonomy scoring even on safety override
+        tax_scores_multi: Dict[str, float] = {}
+        matched_tax_multi: List[TaxonomyMatchDetail] = []
+        top_tax_multi: Optional[str] = None
+        if TAXONOMY_SCORER_AVAILABLE and trigger_engine and decision_config:
+            try:
+                tax_r = score_taxonomy(predict_request.text, trigger_engine, decision_config)
+                tax_scores_multi = tax_r.scores
+                top_tax_multi = tax_r.top_domain
+                matched_tax_multi = [
+                    TaxonomyMatchDetail(domain=d.domain, score=round(d.score, 4), confidence_tier=d.confidence_tier,
+                        priority=d.priority, is_negated=d.is_negated, target_risk_class=d.target_risk_class,
+                        recommended_flow=d.recommended_flow, trigger_count=d.trigger_count, matched_phrases=d.matched_phrases)
+                    for d in tax_r.matched_domains
+                ]
+            except Exception:
+                pass
+        return MultiIntentResponse(
+            detected_intents=[{"intent": escalation_label, "probability": 1.0, "reason": f"SAFETY_OVERRIDE: {keyword_reason}"}],
+            primary_intent=escalation_label,
+            should_escalate=True,
+            taxonomy_scores=tax_scores_multi,
+            matched_taxonomy=matched_tax_multi,
+            top_taxonomy_domain=top_tax_multi,
+            timing=TimingInfo(tokenize_ms=0, inference_ms=0, postprocess_ms=0, total_ms=round(total_time, 3)),
+        )
+    
+    # Split into sentence parts (text only — context is passed separately to tokenizer)
+    parts = split_sentences(text)
+    
+    detected_map = {}  # intent -> max probability
+    should_escalate = False
+    
+    tokenize_time = 0
+    inference_time = 0
+    
+    for part in parts:
+        # Tokenize: text (part) as Segment A, context as Segment B (truncated first)
+        t_start = time.perf_counter()
+        if context:
+            inputs = tokenizer(part, text_pair=context, padding="max_length", truncation="only_second", max_length=MAX_LENGTH, return_tensors="np")
+        else:
+            inputs = tokenizer(part, padding="max_length", truncation=True, max_length=MAX_LENGTH, return_tensors="np")
+        tokenize_time += (time.perf_counter() - t_start) * 1000
+        
+        input_ids = inputs["input_ids"].astype(np.int64)
+        attention_mask = inputs["attention_mask"].astype(np.int64)
+        token_type_ids = None
+        input_names = [inp.name for inp in session.get_inputs()]
+        if "token_type_ids" in input_names:
+            token_type_ids = inputs.get("token_type_ids", np.zeros_like(input_ids)).astype(np.int64)
+        
+        # Inference
+        i_start = time.perf_counter()
+        logits = await run_inference_async(input_ids, attention_mask, token_type_ids)
+        inference_time += (time.perf_counter() - i_start) * 1000
+        
+        probabilities = softmax(logits)
+        
+        # Get top intent for this part
+        top_idx = int(np.argmax(probabilities))
+        top_label = id2label.get(top_idx, f"LABEL_{top_idx}")
+        top_prob = float(probabilities[top_idx])
+        
+        if top_prob >= threshold:
+            if top_label not in detected_map or detected_map[top_label] < top_prob:
+                detected_map[top_label] = top_prob
+        
+        # Check escalation
+        esc_prob = float(probabilities[label2id.get(escalation_label, 0)])
+        if esc_prob >= escalation_threshold:
+            should_escalate = True
+    
+    postprocess_start = time.perf_counter()
+    
+    # Build response
+    detected = [{"intent": k, "probability": round(v, 4)} for k, v in detected_map.items()]
+    detected.sort(key=lambda x: x["probability"], reverse=True)
+    
+    primary_intent = detected[0]["intent"] if detected else "UNKNOWN"
+    
+    # Temporal preprocessor override for multi-intent
+    if temporal_signal and temporal_signal.is_active_emergency and not should_escalate:
+        should_escalate = True
+        if escalation_label not in detected_map:
+            detected.insert(0, {"intent": escalation_label, "probability": 1.0, "reason": f"TEMPORAL_OVERRIDE: {temporal_signal.reason}"})
+        primary_intent = escalation_label
+    
+    postprocess_time = (time.perf_counter() - postprocess_start) * 1000
+    total_time = (time.perf_counter() - total_start) * 1000
+    
+    # Taxonomy scoring (deterministic)
+    tax_scores_m: Dict[str, float] = {}
+    matched_tax_m: List[TaxonomyMatchDetail] = []
+    top_tax_m: Optional[str] = None
+    if TAXONOMY_SCORER_AVAILABLE and trigger_engine and decision_config:
+        try:
+            tax_r = score_taxonomy(predict_request.text, trigger_engine, decision_config)
+            tax_scores_m = tax_r.scores
+            top_tax_m = tax_r.top_domain
+            matched_tax_m = [
+                TaxonomyMatchDetail(domain=d.domain, score=round(d.score, 4), confidence_tier=d.confidence_tier,
+                    priority=d.priority, is_negated=d.is_negated, target_risk_class=d.target_risk_class,
+                    recommended_flow=d.recommended_flow, trigger_count=d.trigger_count, matched_phrases=d.matched_phrases)
+                for d in tax_r.matched_domains
+            ]
+            # SAFETY NET: hard-escalate R3 domains override ML
+            hard_esc_domains = decision_config.hard_escalate_domains
+            for d in tax_r.matched_domains:
+                if d.domain in hard_esc_domains and not d.is_negated and d.score > 0:
+                    if not should_escalate:
+                        should_escalate = True
+                        primary_intent = escalation_label
+                        if escalation_label not in detected_map:
+                            detected.insert(0, {"intent": escalation_label, "probability": 1.0, "reason": f"TAXONOMY_ESCALATION: {d.domain}"})
+                    break
+        except Exception as e:
+            logger.warning("Taxonomy scoring failed in /predict/multi: %s", e)
+
+    return MultiIntentResponse(
+        detected_intents=detected,
+        primary_intent=primary_intent,
+        should_escalate=should_escalate,
+        taxonomy_scores=tax_scores_m,
+        matched_taxonomy=matched_tax_m,
+        top_taxonomy_domain=top_tax_m,
+        timing=TimingInfo(
+            tokenize_ms=round(tokenize_time, 3),
+            inference_ms=round(inference_time, 3),
+            postprocess_ms=round(postprocess_time, 3),
+            total_ms=round(total_time, 3),
+        ),
+    )
+
+
+@app.get("/taxonomy", tags=["Discovery"])
+@limiter.limit("30/minute")
+async def get_taxonomy(
+    request: Request,
+    api_key: str = Depends(verify_api_key),
+):
+    """
+    List all available taxonomy domains with their priority and target risk class.
+
+    Returns every domain the deterministic engine can match against,
+    along with metadata from each domain's rules.yaml.
+    """
+    if not decision_config:
+        return {"domains": [], "count": 0, "message": "Decision engine not loaded"}
+
+    domains = []
+    for name in sorted(decision_config.taxonomy_triggers.keys()):
+        priority = decision_config.get_domain_priority(name)
+        target_risk = decision_config.get_domain_target_risk(name)
+        domains.append({
+            "domain": name,
+            "display_name": name.replace("_", " ").title(),
+            "priority": priority,
+            "target_risk_class": target_risk,
+        })
+    return {"domains": domains, "count": len(domains)}
+
+
+@app.get("/labels")
+@limiter.limit("30/minute")
+async def get_labels(
+    request: Request,
+    api_key: str = Depends(verify_api_key),
+):
+    """Get available intent labels (requires authentication)."""
+    return {"labels": list(label2id.keys())}
+
+
+@app.get("/policy")
+@limiter.limit("10/minute")
+async def get_policy(
+    request: Request,
+    api_key: str = Depends(verify_api_key),
+):
+    """
+    Get current decision policy (requires authentication).
+    
+    This endpoint exposes sensitive threshold information.
+    """
+    audit_logger.info("Policy endpoint accessed")
+    return decision_policy
+
+
+@app.get("/metrics")
+@limiter.limit("60/minute")
+async def get_metrics(
+    request: Request,
+    api_key: str = Depends(verify_api_key),
+):
+    """
+    Get service metrics for monitoring and observability.
+    
+    Returns request counts, latency averages, and throughput stats.
+    Requires authentication.
+    """
+    if not ENABLE_METRICS:
+        raise HTTPException(status_code=404, detail="Metrics disabled")
+    
+    return {
+        "metrics": metrics.get_stats(),
+        "config": {
+            "inference_workers": INFERENCE_WORKERS,
+            "onnx_intra_op_threads": ONNX_INTRA_OP_THREADS,
+            "onnx_inter_op_threads": ONNX_INTER_OP_THREADS,
+            "max_length": MAX_LENGTH,
+            "batching_enabled": ENABLE_BATCHING,
+        },
+        "timestamp": datetime.now(timezone.utc).isoformat(),
+    }
+
+
+@app.get("/ready")
+async def readiness_check(request: Request):
+    """
+    Kubernetes-style readiness probe.
+    
+    Returns 200 if service is ready to accept traffic,
+    503 if not ready (model not loaded).
+    No authentication required for orchestrator probes.
+    """
+    if session is None or tokenizer is None:
+        raise HTTPException(status_code=503, detail="Service not ready")
+    return {"status": "ready"}
+
+
+@app.get("/compliance")
+@limiter.limit("10/minute")
+async def compliance_status(
+    request: Request,
+    api_key: str = Depends(verify_api_key),
+):
+    """
+    Get HIPAA compliance configuration status.
+    
+    Returns current security settings and compliance controls.
+    Requires authentication. For clinical deployment audits.
+    """
+    if not HIPAA_ENABLED:
+        return {
+            "hipaa_module_loaded": False,
+            "message": "HIPAA compliance module not available",
+        }
+    
+    return {
+        "hipaa_module_loaded": True,
+        "compliance_status": get_compliance_status(),
+        "service_info": {
+            "version": "1.0.0",
+            "environment": os.getenv("ENVIRONMENT", "development"),
+            "docs_disabled": DISABLE_DOCS,
+            "auth_required": REQUIRE_AUTH,
+        },
+        "timestamp": datetime.now(timezone.utc).isoformat(),
+    }
+
+
+# =============================================================================
+# STREAMING INTENT ENDPOINTS
+# =============================================================================
+
+# Thread-safe session-based streaming tracker storage
+_streaming_config = None
+_streaming_config_lock = threading.Lock()
+# Store tuple of (tracker, last_access_time) for TTL-based expiration
+_session_trackers: OrderedDict[str, tuple] = OrderedDict()
+_session_trackers_lock = threading.Lock()
+MAX_SESSIONS = int(os.getenv("MAX_STREAMING_SESSIONS", "1000"))
+SESSION_TTL_SECONDS = float(os.getenv("SESSION_TTL_SECONDS", "1800"))  # 30 minutes default
+
+
+def _get_streaming_config():
+    """Get or load streaming config (thread-safe singleton)."""
+    global _streaming_config
+    if _streaming_config is None:
+        with _streaming_config_lock:
+            if _streaming_config is None:
+                from streaming_intent import StreamingConfig
+                _streaming_config = StreamingConfig.from_yaml()
+    return _streaming_config
+
+
+def _run_streaming_inference_sync(text: str, config) -> Dict[str, float]:
+    """Synchronous ONNX inference for streaming (runs in executor)."""
+    if tokenizer is None or session is None:
+        raise RuntimeError("Model not loaded")
+    
+    inputs = tokenizer(
+        text,
+        return_tensors="np",
+        max_length=config.model_max_length,
+        truncation=True,
+        padding="max_length",
+    )
+    
+    # Build input dict with available inputs
+    input_dict = {
+        "input_ids": inputs["input_ids"],
+        "attention_mask": inputs["attention_mask"],
+    }
+    # Add token_type_ids only if model expects it
+    input_names = [inp.name for inp in session.get_inputs()]
+    if "token_type_ids" in input_names:
+        if "token_type_ids" in inputs:
+            input_dict["token_type_ids"] = inputs["token_type_ids"]
+        else:
+            input_dict["token_type_ids"] = np.zeros_like(inputs["input_ids"])
+    
+    outputs = session.run(None, input_dict)
+    
+    logits = outputs[0][0]
+    exp_logits = np.exp(logits - np.max(logits))
+    probs = exp_logits / exp_logits.sum()
+    
+    return {id2label[i]: float(probs[i]) for i in range(len(probs))}
+
+
+async def _run_streaming_inference_async(text: str) -> Dict[str, float]:
+    """Async wrapper for streaming inference using ThreadPoolExecutor."""
+    config = _get_streaming_config()
+    loop = asyncio.get_running_loop()
+    return await loop.run_in_executor(
+        inference_executor,
+        _run_streaming_inference_sync,
+        text,
+        config,
+    )
+
+
+def _create_model_inference_fn() -> callable:
+    """Create model inference function for streaming tracker (sync version for tracker API)."""
+    def model_inference(text: str) -> Dict[str, float]:
+        """Use loaded ONNX model for inference."""
+        config = _get_streaming_config()
+        return _run_streaming_inference_sync(text, config)
+    
+    return model_inference
+
+
+def get_streaming_tracker(session_id: str):
+    """
+    Get or create streaming intent tracker for a specific session (thread-safe).
+    
+    Each session gets its own tracker to prevent state corruption between
+    concurrent requests. Old sessions are evicted based on TTL or when MAX_SESSIONS is reached.
+    """
+    global _session_trackers
+    current_time = time.time()
+    
+    with _session_trackers_lock:
+        # First, clean up expired sessions (TTL-based expiration)
+        expired_sessions = [
+            sid for sid, (_, last_access) in _session_trackers.items()
+            if current_time - last_access > SESSION_TTL_SECONDS
+        ]
+        for sid in expired_sessions:
+            del _session_trackers[sid]
+            logger.debug(f"Expired streaming session {sid}")
+        
+        if session_id in _session_trackers:
+            # Update last access time and move to end (LRU)
+            tracker, _ = _session_trackers[session_id]
+            _session_trackers[session_id] = (tracker, current_time)
+            _session_trackers.move_to_end(session_id)
+            return tracker
+        
+        # Create new tracker for this session
+        try:
+            from streaming_intent import StreamingIntentTracker
+            config = _get_streaming_config()
+            
+            tracker = StreamingIntentTracker(
+                config=config,
+                model_fn=_create_model_inference_fn(),
+            )
+            
+            # Evict oldest session if at capacity
+            while len(_session_trackers) >= MAX_SESSIONS:
+                _session_trackers.popitem(last=False)
+            
+            _session_trackers[session_id] = (tracker, current_time)
+            logger.debug(f"Created streaming tracker for session {session_id}")
+            return tracker
+            
+        except ImportError as e:
+            logger.warning(f"Streaming intent module not available: {e}")
+            raise HTTPException(status_code=501, detail="Streaming intent module not installed")
+
+
+def reset_streaming_tracker(session_id: str) -> bool:
+    """Reset or remove a streaming tracker for a session."""
+    with _session_trackers_lock:
+        if session_id in _session_trackers:
+            tracker, _ = _session_trackers[session_id]
+            tracker.reset()
+            _session_trackers[session_id] = (tracker, time.time())
+            return True
+        return False
+
+
+class StreamChunkRequest(BaseModel):
+    """Request schema for streaming chunk endpoint."""
+    text: str = Field(..., min_length=1, max_length=MAX_INPUT_CHARS, description="STT chunk text")
+    is_final: bool = Field(False, description="Whether this is a finalized STT segment")
+    timestamp_ms: Optional[int] = Field(None, description="Optional timestamp in milliseconds")
+    session_id: Optional[str] = Field(None, description="Session ID for tracking (auto-generated if not provided)")
+
+
+class StreamDecisionResponse(BaseModel):
+    """Response schema for streaming decision."""
+    current_belief: Dict[str, float] = Field(..., description="Current probability distribution over intents")
+    top_intent: str = Field(..., description="Intent with highest probability")
+    top_intent_prob: float = Field(..., description="Probability of top intent")
+    should_escalate: bool = Field(..., description="Whether escalation has been triggered")
+    should_commit: bool = Field(..., description="Whether intent is ready to be committed")
+    committed_intent: Optional[str] = Field(None, description="Final committed intent (if should_commit)")
+    escalation_reason: Optional[str] = Field(None, description="Reason for escalation (if triggered)")
+    window_text: str = Field(..., description="Current rolling window text")
+    step_count: int = Field(..., description="Number of update steps processed")
+    step_latency_ms: float = Field(..., description="Processing time for this step")
+    # Decision engine enrichment (Phase 1 integration)
+    risk_class: Optional[str] = Field(None, description="R0/R1/R2/R3 clinical risk tier")
+    primary_domain: Optional[str] = Field(None, description="Primary clinical domain detected")
+    domain_nominations: Optional[List[Dict[str, Any]]] = Field(None, description="Top domain nominations")
+
+
+@app.post("/stream/chunk", response_model=StreamDecisionResponse, tags=["Streaming"])
+@limiter.limit(RATE_LIMIT)
+async def process_stream_chunk(
+    request: Request,
+    chunk: StreamChunkRequest,
+    api_key: str = Depends(verify_api_key),
+):
+    """
+    Process a streaming STT chunk and return belief state + decision.
+    
+    This endpoint implements HMM-style belief updating for stable intent
+    classification over streaming text. Use for real-time STT processing.
+    
+    **Decision Rules:**
+    - Immediate escalation if P(ESCALATION) >= 0.85
+    - Escalate if P(ESCALATION) >= 0.60 for 3 consecutive steps
+    - Commit non-escalation intent if top_prob >= 0.70 AND stable for 3 steps
+    
+    **Usage:**
+    1. Send chunks as they arrive from STT
+    2. Set `is_final=true` for finalized STT segments
+    3. Check `should_escalate` for immediate clinical escalation
+    4. Check `should_commit` and `committed_intent` for final classification
+    """
+    try:
+        from streaming_intent import Chunk
+        
+        # Get or generate session ID for thread-safe tracking
+        session_id = chunk.session_id or str(uuid.uuid4())
+        tracker = get_streaming_tracker(session_id)
+        
+        chunk_obj = Chunk(
+            text=chunk.text,
+            is_final=chunk.is_final,
+            timestamp_ms=chunk.timestamp_ms,
+        )
+        
+        # Run tracker update in executor to prevent blocking the event loop
+        # (tracker.update calls synchronous ONNX inference internally)
+        loop = asyncio.get_running_loop()
+        decision = await loop.run_in_executor(
+            inference_executor, tracker.update, chunk_obj
+        )
+        
+        # Safety override — use decision engine if available, else legacy keywords
+        should_escalate = decision.should_escalate
+        escalation_reason = decision.escalation_reason
+        risk_class_str = None
+        primary_domain_str = None
+        domain_nom_list = None
+
+        # Determine text to analyze (prefer window_text for cross-chunk safety)
+        safety_text = decision.window_text or chunk.text
+
+        if DECISION_ENGINE_AVAILABLE and domain_nominator is not None:
+            # Always run decision engine for enrichment (risk_class, domain, nominations)
+            nominations = domain_nominator.nominate(
+                text=safety_text,
+                ml_label=decision.top_intent,
+                ml_probabilities=decision.current_belief,
+            )
+            assessment = risk_classifier.assess(
+                nominations=nominations,
+                ml_label=decision.top_intent,
+                ml_confidence=decision.top_intent_prob,
+            )
+            risk_class_str = assessment.risk_class.value
+            primary_domain_str = assessment.primary_domain
+
+            # Upgrade escalation if engine detects R2+ and tracker hasn't already
+            if not should_escalate and assessment.risk_class >= RiskClass.R2:
+                should_escalate = True
+                if assessment.hard_escalate:
+                    escalation_reason = f"HARD_ESCALATE: {assessment.primary_domain} → {assessment.risk_class.value}"
+                elif assessment.safety_override:
+                    escalation_reason = f"SAFETY_OVERRIDE: {assessment.primary_domain} → {assessment.risk_class.value}"
+                else:
+                    escalation_reason = f"CLINICAL_RISK: {assessment.primary_domain} → {assessment.risk_class.value}"
+            elif should_escalate and assessment.risk_class < RiskClass.R2:
+                # Tracker escalated but engine says R0/R1 — belt+suspenders upgrade
+                risk_class_str = "R2"
+
+            domain_nom_list = [
+                {"domain": n.domain, "confidence": n.confidence_tier.value, "negated": n.is_negated}
+                for n in nominations[:5]
+            ]
+        elif not should_escalate:
+            # Fallback to legacy safety keywords
+            keyword_match, keyword_reason = check_safety_keywords(chunk.text)
+            if not keyword_match and decision.window_text:
+                keyword_match, keyword_reason = check_safety_keywords(decision.window_text)
+            if keyword_match:
+                should_escalate = True
+                escalation_reason = keyword_reason
+                risk_class_str = "R2"
+
+        # Audit log escalations
+        if should_escalate and HIPAA_ENABLED:
+            hipaa_audit.log_escalation(
+                request_id=getattr(request.state, 'request_id', 'unknown'),
+                client_ip=request.client.host if request.client else 'unknown',
+                escalation_type=escalation_reason or "streaming_escalation",
+                confidence=decision.current_belief.get("ESCALATION", 0),
+            )
+        
+        return StreamDecisionResponse(
+            current_belief=decision.current_belief,
+            top_intent=decision.top_intent,
+            top_intent_prob=decision.top_intent_prob,
+            should_escalate=should_escalate,
+            should_commit=decision.should_commit,
+            committed_intent=decision.committed_intent,
+            escalation_reason=escalation_reason,
+            window_text=decision.window_text,
+            step_count=decision.step_count,
+            step_latency_ms=round(decision.step_latency_ms, 3),
+            risk_class=risk_class_str,
+            primary_domain=primary_domain_str,
+            domain_nominations=domain_nom_list,
+        )
+    except ImportError:
+        raise HTTPException(status_code=501, detail="Streaming intent module not available")
+    except Exception as e:
+        logger.error(f"Streaming chunk error: {e}")
+        raise HTTPException(status_code=500, detail="Streaming processing failed")
+
+
+class StreamResetRequest(BaseModel):
+    """Request schema for stream reset endpoint."""
+    session_id: str = Field(..., min_length=1, description="Session ID to reset")
+
+
+@app.post("/stream/reset", tags=["Streaming"])
+@limiter.limit("30/minute")
+async def reset_stream(
+    request: Request,
+    reset_request: StreamResetRequest,
+    api_key: str = Depends(verify_api_key),
+):
+    """
+    Reset streaming tracker state for a specific session.
+    
+    Call this when starting a new conversation/session to clear
+    accumulated text buffer and belief state.
+    """
+    try:
+        was_reset = reset_streaming_tracker(reset_request.session_id)
+        if was_reset:
+            return {"status": "reset", "session_id": reset_request.session_id, "message": "Streaming tracker reset"}
+        else:
+            return {"status": "not_found", "session_id": reset_request.session_id, "message": "Session not found (may already be expired)"}
+    except ImportError:
+        raise HTTPException(status_code=501, detail="Streaming intent module not available")
+
+
+@app.get("/stream/metrics", tags=["Streaming"])
+@limiter.limit("30/minute")
+async def get_stream_metrics(
+    request: Request,
+    session_id: Optional[str] = None,
+    api_key: str = Depends(verify_api_key),
+):
+    """
+    Get streaming tracker metrics for a specific session or aggregate.
+    
+    Returns escalation count, gray zone rate, average steps to decision.
+    """
+    try:
+        if session_id:
+            with _session_trackers_lock:
+                if session_id in _session_trackers:
+                    tracker, _ = _session_trackers[session_id]
+                    metrics_data = tracker.get_metrics()
+                else:
+                    raise HTTPException(status_code=404, detail=f"Session {session_id} not found")
+        else:
+            # Return aggregate info about all sessions
+            with _session_trackers_lock:
+                metrics_data = {
+                    "active_sessions": len(_session_trackers),
+                    "max_sessions": MAX_SESSIONS,
+                }
+        return {
+            "streaming_metrics": metrics_data,
+            "timestamp": datetime.now(timezone.utc).isoformat(),
+        }
+    except ImportError:
+        raise HTTPException(status_code=501, detail="Streaming intent module not available")
+
+
+@app.get("/stream/config", tags=["Streaming"])
+@limiter.limit("10/minute")
+async def get_stream_config(
+    request: Request,
+    api_key: str = Depends(verify_api_key),
+):
+    """
+    Get streaming intent configuration.
+    
+    Returns thresholds, transition matrix info, and window settings.
+    """
+    try:
+        config = _get_streaming_config()
+        return {
+            "thresholds": {
+                "theta_hi": config.theta_hi,
+                "theta_med": config.theta_med,
+                "theta_lock": config.theta_lock,
+                "K": config.K,
+            },
+            "emission": {
+                "alpha": config.alpha,
+                "epsilon": config.epsilon,
+            },
+            "window": {
+                "max_tokens": config.max_tokens,
+                "max_tokens_limit": config.max_tokens_limit,
+            },
+            "debounce": {
+                "debounce_ms": config.debounce_ms,
+                "min_change_chars": config.min_change_chars,
+            },
+            "intents": config.intents,
+        }
+    except ImportError:
+        raise HTTPException(status_code=501, detail="Streaming intent module not available")
+
+
+@app.exception_handler(Exception)
+async def global_exception_handler(request: Request, exc: Exception):
+    """Global exception handler - never expose internal details."""
+    request_id = getattr(request.state, 'request_id', 'unknown')
+    # Log full error internally
+    logger.error(f"Unhandled exception [request_id={request_id}]: {exc}", exc_info=True)
+    # Return generic error to client
+    return JSONResponse(
+        status_code=500,
+        content={
+            "detail": "Internal server error",
+            "request_id": request_id,  # Allow user to reference for support
+        },
+        headers={"X-Request-ID": request_id},
+    )
+
+
+if __name__ == "__main__":
+    import uvicorn
+    uvicorn.run(app, host="0.0.0.0", port=8000)
diff --git a/service/hipaa_config.py b/service/hipaa_config.py
new file mode 100644
index 0000000000000000000000000000000000000000..14c5185c3c1d915f1e653299682febd097007ed8
--- /dev/null
+++ b/service/hipaa_config.py
@@ -0,0 +1,405 @@
+#!/usr/bin/env python3
+"""
+HIPAA Compliance Configuration for Clinical Deployment.
+
+This module provides security configurations and utilities to help
+ensure HIPAA compliance for the DCE Intent Classifier service.
+
+IMPORTANT: This is a helper module. Full HIPAA compliance requires
+organizational policies, training, and infrastructure beyond this code.
+"""
+
+import hashlib
+import logging
+import os
+import re
+from datetime import datetime, timezone
+from typing import Any, Dict, List, Optional, Tuple
+
+# =============================================================================
+# HIPAA SECURITY CONFIGURATION
+# =============================================================================
+
+# PHI (Protected Health Information) patterns to detect and redact in logs
+PHI_PATTERNS = {
+    "ssn": re.compile(r"\b\d{3}-\d{2}-\d{4}\b"),
+    "phone": re.compile(r"\b\d{3}[-.]?\d{3}[-.]?\d{4}\b"),
+    "email": re.compile(r"\b[A-Za-z0-9._%+-]+@[A-Za-z0-9.-]+\.[A-Z|a-z]{2,}\b"),
+    "mrn": re.compile(r"\b(MRN|mrn|Medical Record)[\s:#]*\d{6,12}\b", re.IGNORECASE),
+    "dob": re.compile(r"\b(DOB|dob|birth)[\s:#]*\d{1,2}[/-]\d{1,2}[/-]\d{2,4}\b", re.IGNORECASE),
+    "credit_card": re.compile(r"\b\d{4}[-\s]?\d{4}[-\s]?\d{4}[-\s]?\d{4}\b"),
+}
+
+# Session timeout in seconds (HIPAA recommends automatic logoff)
+SESSION_TIMEOUT_SECONDS = int(os.getenv("SESSION_TIMEOUT", "900"))  # 15 minutes default
+
+# Audit log retention days (HIPAA requires 6 years minimum)
+AUDIT_LOG_RETENTION_DAYS = int(os.getenv("AUDIT_RETENTION_DAYS", "2190"))  # 6 years
+
+# Maximum failed login attempts before lockout
+MAX_FAILED_ATTEMPTS = int(os.getenv("MAX_FAILED_ATTEMPTS", "5"))
+LOCKOUT_DURATION_SECONDS = int(os.getenv("LOCKOUT_DURATION", "900"))  # 15 minutes
+
+# Encryption requirements
+REQUIRE_TLS = os.getenv("REQUIRE_TLS", "true").lower() == "true"
+MIN_TLS_VERSION = os.getenv("MIN_TLS_VERSION", "1.2")
+
+# Data handling
+LOG_PHI = os.getenv("LOG_PHI", "false").lower() == "true"  # Never log PHI by default
+REDACT_PHI_IN_LOGS = os.getenv("REDACT_PHI", "true").lower() == "true"
+
+
+# =============================================================================
+# PHI DETECTION AND REDACTION
+# =============================================================================
+
+def detect_phi(text: str) -> List[Tuple[str, str]]:
+    """
+    Detect potential PHI in text.
+    
+    Returns:
+        List of tuples (phi_type, matched_text)
+    """
+    findings = []
+    for phi_type, pattern in PHI_PATTERNS.items():
+        matches = pattern.findall(text)
+        for match in matches:
+            findings.append((phi_type, match))
+    return findings
+
+
+def redact_phi(text: str) -> str:
+    """
+    Redact potential PHI from text for safe logging.
+    
+    Returns:
+        Text with PHI replaced by [REDACTED-{type}]
+    """
+    redacted = text
+    for phi_type, pattern in PHI_PATTERNS.items():
+        redacted = pattern.sub(f"[REDACTED-{phi_type.upper()}]", redacted)
+    return redacted
+
+
+def hash_identifier(identifier: str) -> str:
+    """
+    Create a one-way hash of an identifier for audit logging.
+    
+    This allows tracking without storing actual PHI.
+    
+    WARNING: In production, set PHI_HASH_SALT to a unique secret value.
+    """
+    salt = os.getenv("PHI_HASH_SALT", "")
+    environment = os.getenv("ENVIRONMENT", "development").lower()
+    
+    if not salt:
+        if environment == "production":
+            raise RuntimeError(
+                "CRITICAL: PHI_HASH_SALT environment variable must be set in production! "
+                "This is required for HIPAA-compliant identifier hashing."
+            )
+        import logging
+        logging.getLogger("hipaa_audit").warning(
+            "PHI_HASH_SALT not configured - using default. Set this to a unique secret in production!"
+        )
+        salt = "dce-intent-classifier-default"
+    return hashlib.sha256(f"{salt}:{identifier}".encode()).hexdigest()[:16]
+
+
+# =============================================================================
+# AUDIT LOGGING
+# =============================================================================
+
+class HIPAAAuditLogger:
+    """
+    HIPAA-compliant audit logger.
+    
+    Tracks all access to the system with required audit fields.
+    """
+    
+    def __init__(self, logger_name: str = "hipaa_audit"):
+        self.logger = logging.getLogger(logger_name)
+        self.logger.setLevel(logging.INFO)
+    
+    def log_access(
+        self,
+        user_id: Optional[str],
+        action: str,
+        resource: str,
+        client_ip: str,
+        request_id: str,
+        success: bool,
+        details: Optional[str] = None,
+    ) -> None:
+        """
+        Log an access event with HIPAA-required fields.
+        
+        Required fields per HIPAA:
+        - User identification (hashed if applicable)
+        - Date and time of access
+        - Action performed
+        - Resource accessed
+        - Success/failure status
+        """
+        timestamp = datetime.now(timezone.utc).isoformat()
+        
+        # Hash user_id if present to avoid logging actual identifiers
+        user_hash = hash_identifier(user_id) if user_id else "anonymous"
+        
+        # Redact any PHI in details
+        safe_details = redact_phi(details) if details else None
+        
+        log_entry = {
+            "timestamp": timestamp,
+            "user_hash": user_hash,
+            "action": action,
+            "resource": resource,
+            "client_ip": client_ip,
+            "request_id": request_id,
+            "success": success,
+            "details": safe_details,
+        }
+        
+        self.logger.info(f"HIPAA_AUDIT: {log_entry}")
+    
+    def log_escalation(
+        self,
+        request_id: str,
+        client_ip: str,
+        escalation_type: str,
+        confidence: float,
+    ) -> None:
+        """
+        Log a clinical escalation event.
+        
+        This is critical for tracking urgent patient safety events.
+        """
+        timestamp = datetime.now(timezone.utc).isoformat()
+        
+        log_entry = {
+            "timestamp": timestamp,
+            "event_type": "CLINICAL_ESCALATION",
+            "escalation_type": escalation_type,
+            "confidence": round(confidence, 4),
+            "request_id": request_id,
+            "client_ip": client_ip,
+        }
+        
+        self.logger.warning(f"ESCALATION_ALERT: {log_entry}")
+    
+    def log_security_event(
+        self,
+        event_type: str,
+        client_ip: str,
+        request_id: str,
+        details: str,
+    ) -> None:
+        """
+        Log a security-related event (failed auth, rate limit, etc).
+        """
+        timestamp = datetime.now(timezone.utc).isoformat()
+        
+        log_entry = {
+            "timestamp": timestamp,
+            "event_type": f"SECURITY_{event_type}",
+            "client_ip": client_ip,
+            "request_id": request_id,
+            "details": redact_phi(details),
+        }
+        
+        self.logger.warning(f"SECURITY_EVENT: {log_entry}")
+
+
+# =============================================================================
+# SECURITY HEADERS
+# =============================================================================
+
+SECURITY_HEADERS = {
+    "X-Content-Type-Options": "nosniff",
+    "X-Frame-Options": "DENY",
+    "X-XSS-Protection": "1; mode=block",
+    "Strict-Transport-Security": "max-age=31536000; includeSubDomains",
+    "Cache-Control": "no-store, no-cache, must-revalidate, private",
+    "Pragma": "no-cache",
+    "Referrer-Policy": "strict-origin-when-cross-origin",
+    "Content-Security-Policy": "default-src 'self'; script-src 'self'; style-src 'self' 'unsafe-inline'; img-src 'self' data:; font-src 'self'; connect-src 'self'; frame-ancestors 'none'",
+}
+
+# Relaxed headers for docs endpoints (allows Swagger UI to load)
+DOCS_SECURITY_HEADERS = {
+    "X-Content-Type-Options": "nosniff",
+    "X-Frame-Options": "SAMEORIGIN",
+    "X-XSS-Protection": "1; mode=block",
+    "Referrer-Policy": "strict-origin-when-cross-origin",
+}
+
+
+def get_security_headers(is_docs: bool = False) -> Dict[str, str]:
+    """Get security headers for responses."""
+    if is_docs:
+        return DOCS_SECURITY_HEADERS.copy()
+    return SECURITY_HEADERS.copy()
+
+
+# =============================================================================
+# INPUT VALIDATION FOR CLINICAL SAFETY
+# =============================================================================
+
+# Words/phrases that should trigger extra caution in clinical context
+CLINICAL_SAFETY_KEYWORDS = {
+    "high_urgency": [
+        "suicide", "suicidal", "kill myself", "end my life", "want to die",
+        "hurt myself", "self harm", "overdose", "od'd", "not breathing",
+        "unconscious", "unresponsive", "chest pain", "heart attack", "stroke",
+        "seizure", "bleeding heavily", "cant breathe", "allergic reaction",
+    ],
+    "mental_health": [
+        "depressed", "depression", "anxiety", "panic attack", "voices",
+        "hallucinating", "psychotic", "manic", "bipolar", "schizophrenia",
+        "ptsd", "trauma", "abuse", "assault", "rape",
+    ],
+    "substance": [
+        "overdose", "withdrawal", "detox", "drunk", "high", "using",
+        "relapse", "addiction", "alcoholic", "drugs",
+    ],
+}
+
+
+def _has_temporal_resolution(text_lower: str, keyword: str) -> bool:
+    """
+    Detect if a safety keyword appears in a resolved/historical context.
+    
+    Returns True if the keyword is described as past/resolved (should NOT escalate).
+    Returns False if the keyword appears acute/current (SHOULD escalate).
+    
+    Safety bias: if uncertain, returns False (i.e. escalate).
+    """
+    # Find keyword position for proximity-based checks
+    kw_pos = text_lower.find(keyword)
+    if kw_pos == -1:
+        return False
+
+    # Extract a window around the keyword for context analysis
+    window_start = max(0, kw_pos - 80)
+    window_end = min(len(text_lower), kw_pos + len(keyword) + 80)
+    window = text_lower[window_start:window_end]
+
+    # Past-tense / historical markers that precede the keyword
+    past_prefixes = [
+        r"\bi\s+had\b", r"\bi\s+used\s+to\s+have\b", r"\bi\s+was\s+having\b",
+        r"\bi\s+experienced\b", r"\bi\s+went\s+through\b", r"\bi\s+suffered\b",
+        r"\bi\s+got\b", r"\bpreviously\s+had\b", r"\bhistory\s+of\b",
+        r"\bpast\s+episode\b", r"\bformer\b", r"\bprevious\b",
+        r"\blast\s+(week|month|year|time|night|tuesday|wednesday|thursday|friday|saturday|sunday|monday)\b",
+        r"\byesterday\b", r"\b\d+\s+(days?|weeks?|months?|years?)\s+ago\b",
+        r"\bback\s+in\b", r"\bwhen\s+i\s+was\b", r"\ba\s+while\s+ago\b",
+        r"\bin\s+the\s+past\b", r"\ba\s+few\s+(days|weeks|months)\s+ago\b",
+        r"\bearlier\s+(this|today|last)\b", r"\bused\s+to\b",
+        r"\bhad\s+a\b", r"\bhad\s+some\b", r"\bhad\s+an\b",
+    ]
+
+    # Resolution / improvement markers anywhere in the text
+    resolution_markers = [
+        r"\bfeeling\s+(much\s+)?better\b", r"\bi'?m\s+(feeling\s+)?(much\s+)?better\b",
+        r"\bimproved\b", r"\bresolved\b", r"\bwent\s+away\b", r"\bgone\s+now\b",
+        r"\bno\s+longer\b", r"\bstopped\b", r"\bcleared\s+up\b",
+        r"\bfine\s+now\b", r"\bokay\s+now\b", r"\bok\s+now\b",
+        r"\brecovered\b", r"\brecovering\b", r"\bheal(ed|ing)\b",
+        r"\bwent\s+to\s+(the\s+)?(doctor|er|hospital|urgent\s+care|clinic)\b",
+        r"\bsaw\s+(the\s+)?(doctor|my\s+doctor|a\s+doctor|specialist)\b",
+        r"\bbeen\s+treated\b", r"\bgot\s+(it\s+)?checked\b",
+        r"\bthey\s+said\s+(it'?s|i'?m)\s+(fine|ok|normal|nothing)\b",
+        r"\bnot\s+anymore\b", r"\bdoesn'?t\s+hurt\s+(anymore|now)\b",
+        r"\bfeeling\s+good\b", r"\bmuch\s+improved\b",
+        r"\bunder\s+control\b", r"\bmanaged\b", r"\bstable\b",
+    ]
+
+    # "Still active" markers that OVERRIDE past tense (should still escalate)
+    still_active_markers = [
+        r"\bstill\s+(have|having|feel|feeling|hurts?|experiencing)\b",
+        r"\bgetting\s+worse\b", r"\bnot\s+getting\s+better\b",
+        r"\bcame\s+back\b", r"\bback\s+again\b", r"\breturned\b",
+        r"\bwon'?t\s+(stop|go\s+away)\b", r"\bkeeps?\s+coming\b",
+        r"\bright\s+now\b", r"\bat\s+this\s+moment\b",
+        r"\bcurrently\b", r"\bpresently\b",
+        r"\bi'?m\s+having\b", r"\bi\s+have\b", r"\bi\s+feel\b",
+        r"\bworried\s+(it'?s|about)\b", r"\bscared\b",
+        r"\bworse\s+(than|today|now)\b",
+        # BUT-clause reversals: "felt better but now the pain is back"
+        r"\bbut\s+now\b", r"\bbut\s+today\b", r"\bbut\s+currently\b",
+        r"\bbut\s+(it'?s?|the|i'?m|i\s+am|i\s+have|they)\b",
+        r"\bhowever\s+(now|today|it'?s?|the|i'?m)\b",
+        r"\bexcept\s+(now|today|it'?s?|the)\b",
+        # Recurrence patterns
+        r"\b(it'?s?|pain|symptoms?)\s+(is\s+)?back\b",
+        r"\bflaring\s+up\b", r"\bacting\s+up\b",
+        r"\bstarted\s+again\b", r"\bhappening\s+again\b",
+    ]
+
+    # Check for "still active" signals first — if present, do NOT suppress
+    for pattern in still_active_markers:
+        if re.search(pattern, text_lower):
+            return False
+
+    # Check for past-tense prefix near the keyword
+    has_past = any(re.search(p, window) for p in past_prefixes)
+
+    # Check for resolution markers anywhere in full text
+    has_resolution = any(re.search(p, text_lower) for p in resolution_markers)
+
+    # Need BOTH past tense AND resolution to suppress escalation
+    # This is the conservative approach — just past tense alone is not enough
+    return has_past and has_resolution
+
+
+def check_clinical_safety_keywords(text: str) -> Dict[str, List[str]]:
+    """
+    Check text for clinical safety keywords with temporal context awareness.
+    
+    Returns dict of category -> matched keywords.
+    Suppresses matches when keywords appear in clearly resolved/historical context.
+    """
+    text_lower = text.lower()
+    matches = {}
+    
+    for category, keywords in CLINICAL_SAFETY_KEYWORDS.items():
+        found = []
+        for kw in keywords:
+            if kw in text_lower:
+                # Check if keyword is in a resolved/historical context
+                if _has_temporal_resolution(text_lower, kw):
+                    continue  # Suppress — past/resolved
+                found.append(kw)
+        if found:
+            matches[category] = found
+    
+    return matches
+
+
+# =============================================================================
+# COMPLIANCE CHECKLIST
+# =============================================================================
+
+def get_compliance_status() -> Dict[str, Any]:
+    """
+    Get current HIPAA compliance configuration status.
+    
+    Returns a dict indicating which controls are enabled.
+    """
+    return {
+        "authentication_required": os.getenv("REQUIRE_AUTH", "true").lower() == "true",
+        "tls_required": REQUIRE_TLS,
+        "phi_logging_disabled": not LOG_PHI,
+        "phi_redaction_enabled": REDACT_PHI_IN_LOGS,
+        "session_timeout_configured": SESSION_TIMEOUT_SECONDS > 0,
+        "audit_logging_enabled": True,
+        "rate_limiting_enabled": True,
+        "input_sanitization_enabled": True,
+        "security_headers_configured": True,
+        "min_tls_version": MIN_TLS_VERSION,
+        "audit_retention_days": AUDIT_LOG_RETENTION_DAYS,
+    }
+
+
+# Global audit logger instance
+hipaa_audit = HIPAAAuditLogger()
diff --git a/service/run.bat b/service/run.bat
new file mode 100644
index 0000000000000000000000000000000000000000..7089a680ebcb6ec747ce12cad02a14da1afde512
--- /dev/null
+++ b/service/run.bat
@@ -0,0 +1,35 @@
+@echo off
+REM Start DCE Intent Classifier Service (Windows)
+REM Usage: service\run.bat
+
+setlocal
+
+REM Default configuration
+if "%HOST%"=="" set HOST=0.0.0.0
+if "%PORT%"=="" set PORT=8000
+if "%MODEL_DIR%"=="" set MODEL_DIR=artifacts\onnx_int8
+if "%POLICY_PATH%"=="" set POLICY_PATH=artifacts\config\decision_policy.json
+if "%MAX_LENGTH%"=="" set MAX_LENGTH=64
+
+echo ==============================================
+echo DCE Intent Classifier Service
+echo ==============================================
+echo Host: %HOST%
+echo Port: %PORT%
+echo Model: %MODEL_DIR%
+echo Policy: %POLICY_PATH%
+echo Max Length: %MAX_LENGTH%
+echo ==============================================
+
+REM Check if model exists
+if not exist "%MODEL_DIR%\model.onnx" (
+    echo ERROR: Model not found at %MODEL_DIR%\model.onnx
+    echo Run 'task_runner.bat train' and 'task_runner.bat export_onnx' first
+    exit /b 1
+)
+
+REM Start server
+echo Starting server...
+uvicorn service.app:app --host %HOST% --port %PORT%
+
+endlocal
diff --git a/service/run.sh b/service/run.sh
new file mode 100644
index 0000000000000000000000000000000000000000..d203cbe70a5f1185c444b80b6e5cf30343404c99
--- /dev/null
+++ b/service/run.sh
@@ -0,0 +1,81 @@
+#!/bin/bash
+# Start DCE Intent Classifier Service
+# Usage: ./service/run.sh [--reload] [--production]
+
+set -e
+
+# Default configuration
+HOST="${HOST:-0.0.0.0}"
+PORT="${PORT:-8000}"
+WORKERS="${WORKERS:-1}"
+MODEL_DIR="${MODEL_DIR:-artifacts/onnx_int8}"
+POLICY_PATH="${POLICY_PATH:-artifacts/config/decision_policy.json}"
+MAX_LENGTH="${MAX_LENGTH:-64}"
+
+# Scalability configuration
+INFERENCE_WORKERS="${INFERENCE_WORKERS:-4}"
+ONNX_INTRA_OP_THREADS="${ONNX_INTRA_OP_THREADS:-4}"
+ONNX_INTER_OP_THREADS="${ONNX_INTER_OP_THREADS:-1}"
+ENABLE_METRICS="${ENABLE_METRICS:-true}"
+
+# Security configuration
+REQUIRE_AUTH="${REQUIRE_AUTH:-true}"
+API_KEY="${API_KEY:-}"
+
+# Export environment variables
+export MODEL_DIR
+export POLICY_PATH
+export MAX_LENGTH
+export INFERENCE_WORKERS
+export ONNX_INTRA_OP_THREADS
+export ONNX_INTER_OP_THREADS
+export ENABLE_METRICS
+export REQUIRE_AUTH
+export API_KEY
+
+echo "=============================================="
+echo "DCE Intent Classifier Service"
+echo "=============================================="
+echo "Host: $HOST"
+echo "Port: $PORT"
+echo "Workers: $WORKERS"
+echo "Model: $MODEL_DIR"
+echo "Policy: $POLICY_PATH"
+echo "Max Length: $MAX_LENGTH"
+echo "Inference Workers: $INFERENCE_WORKERS"
+echo "ONNX Intra-Op Threads: $ONNX_INTRA_OP_THREADS"
+echo "Auth Required: $REQUIRE_AUTH"
+echo "Metrics Enabled: $ENABLE_METRICS"
+echo "=============================================="
+
+# Check if model exists
+if [ ! -f "$MODEL_DIR/model.onnx" ]; then
+    echo "ERROR: Model not found at $MODEL_DIR/model.onnx"
+    echo "Run 'make train && make export_onnx && make quantize' first"
+    exit 1
+fi
+
+# Check API key in production
+if [ "$REQUIRE_AUTH" = "true" ] && [ -z "$API_KEY" ]; then
+    echo "WARNING: REQUIRE_AUTH=true but API_KEY is not set!"
+    echo "Set API_KEY environment variable or set REQUIRE_AUTH=false for development"
+fi
+
+# Start server
+if [ "$1" = "--reload" ]; then
+    echo "Starting with hot reload (development mode)..."
+    uvicorn service.app:app --host "$HOST" --port "$PORT" --reload
+elif [ "$1" = "--production" ]; then
+    echo "Starting production server with Gunicorn..."
+    gunicorn service.app:app \
+        -w "$WORKERS" \
+        -k uvicorn.workers.UvicornWorker \
+        --bind "$HOST:$PORT" \
+        --timeout 30 \
+        --graceful-timeout 10 \
+        --access-logfile - \
+        --error-logfile -
+else
+    echo "Starting server with Uvicorn..."
+    uvicorn service.app:app --host "$HOST" --port "$PORT" --workers "$WORKERS"
+fi
diff --git a/service/taxonomy_scorer.py b/service/taxonomy_scorer.py
new file mode 100644
index 0000000000000000000000000000000000000000..6fb2bcb019d4da379a0671978b99ef79e22d9103
--- /dev/null
+++ b/service/taxonomy_scorer.py
@@ -0,0 +1,150 @@
+"""
+Taxonomy Scorer — deterministic scoring for all taxonomy domains.
+
+Converts the TaxonomyTriggerEngine match results into a flat dict of
+domain_name → float score (0.0–1.0) for every known domain, plus
+detailed match info for domains that actually triggered.
+"""
+
+from __future__ import annotations
+
+import logging
+from dataclasses import dataclass, field
+from typing import Any, Dict, List, Optional, Tuple
+
+logger = logging.getLogger("service.taxonomy_scorer")
+
+# Score mapping for confidence tiers
+_TIER_SCORES = {
+    "high": 0.95,
+    "medium": 0.65,
+    "low": 0.30,
+    "none": 0.0,
+}
+
+
+@dataclass
+class TaxonomyDomainResult:
+    """Detailed result for a single taxonomy domain."""
+    domain: str
+    score: float
+    confidence_tier: str          # "high", "medium", "low", "none"
+    priority: int
+    is_negated: bool
+    negation_action: Optional[str]  # "suppress", "downgrade_confidence", None
+    target_risk_class: Optional[str]
+    recommended_flow: Optional[str]
+    trigger_count: int
+    matched_phrases: List[str] = field(default_factory=list)
+
+
+@dataclass
+class TaxonomyScoreResult:
+    """Full taxonomy scoring result across all domains."""
+    scores: Dict[str, float]                    # domain → score (ALL domains)
+    matched_domains: List[TaxonomyDomainResult] # Only domains with score > 0, sorted desc
+    top_domain: Optional[str]                   # Highest-scoring domain name
+    top_score: float                            # Highest score
+    domain_count: int                           # Total number of known domains
+
+
+def score_taxonomy(
+    text: str,
+    trigger_engine: Any,
+    decision_config: Any,
+) -> TaxonomyScoreResult:
+    """
+    Score text against ALL taxonomy domains deterministically.
+
+    Args:
+        text: Patient utterance
+        trigger_engine: TaxonomyTriggerEngine instance
+        decision_config: DecisionConfigLoader instance
+
+    Returns:
+        TaxonomyScoreResult with scores for every domain
+    """
+    all_domain_names = sorted(decision_config.taxonomy_triggers.keys())
+
+    # Run deterministic trigger matching against all domains
+    match_results = trigger_engine.match_all(text)
+
+    scores: Dict[str, float] = {}
+    matched_domains: List[TaxonomyDomainResult] = []
+
+    for domain_name in all_domain_names:
+        if domain_name in match_results:
+            result = match_results[domain_name]
+
+            # Convert effective confidence tier to score
+            tier_value = result.effective_confidence.value  # "high", "medium", "low", "none"
+            score = _TIER_SCORES.get(tier_value, 0.0)
+
+            # Get negation info
+            is_negated = False
+            negation_action = None
+            if result.negation_result and result.negation_result.is_negated:
+                is_negated = True
+                negation_action = result.negation_result.action.value if hasattr(result.negation_result.action, 'value') else str(result.negation_result.action)
+
+            # Get target risk class from rules
+            target_risk = decision_config.get_domain_target_risk(domain_name)
+
+            # Get recommended flow from rules
+            recommended_flow = _resolve_flow_for_tier(
+                decision_config, domain_name, tier_value
+            )
+
+            # Collect matched phrases
+            matched_phrases = []
+            for m in result.matches:
+                if hasattr(m, 'matched_span') and m.matched_span:
+                    matched_phrases.append(m.matched_span)
+                elif hasattr(m, 'matched_text') and m.matched_text:
+                    matched_phrases.append(m.matched_text)
+
+            domain_result = TaxonomyDomainResult(
+                domain=domain_name,
+                score=score,
+                confidence_tier=tier_value,
+                priority=result.priority,
+                is_negated=is_negated,
+                negation_action=negation_action,
+                target_risk_class=target_risk,
+                recommended_flow=recommended_flow,
+                trigger_count=len(result.matches),
+                matched_phrases=matched_phrases[:5],  # Limit to top 5
+            )
+            matched_domains.append(domain_result)
+            scores[domain_name] = score
+        else:
+            scores[domain_name] = 0.0
+
+    # Sort matched domains by score descending, then by priority descending
+    matched_domains.sort(key=lambda d: (d.score, d.priority), reverse=True)
+
+    top_domain = matched_domains[0].domain if matched_domains else None
+    top_score = matched_domains[0].score if matched_domains else 0.0
+
+    return TaxonomyScoreResult(
+        scores=scores,
+        matched_domains=matched_domains,
+        top_domain=top_domain,
+        top_score=top_score,
+        domain_count=len(all_domain_names),
+    )
+
+
+def _resolve_flow_for_tier(
+    config: Any, domain_name: str, tier_value: str
+) -> Optional[str]:
+    """Resolve recommended flow from domain rules based on confidence tier."""
+    rules = config.get_domain_decision_rules(domain_name)
+    if not rules:
+        return None
+    for rule in rules:
+        conditions = rule.get("if", {})
+        conf_required = conditions.get("confidence")
+        if conf_required and conf_required == tier_value:
+            return rule.get("then", {}).get("flow")
+    return None
diff --git a/service/temporal_preprocessor.py b/service/temporal_preprocessor.py
new file mode 100644
index 0000000000000000000000000000000000000000..1bf5d3ed3bdd23e167125ac7fc8faa3175201835
--- /dev/null
+++ b/service/temporal_preprocessor.py
@@ -0,0 +1,299 @@
+"""
+Temporal Preprocessor for Clinical Intent Classification.
+
+Rule-based preprocessing layer that runs BEFORE the ML model to handle
+temporal context that BERT struggles with:
+
+1. BUT-clause reversals: "I felt better but now the pain is back"
+   → Extracts the active complaint, discards the resolved prefix.
+
+2. Proxy/third-party urgency: "My mom says her chest hurts really bad"
+   → Detects active urgency even when reported through a third party.
+
+3. Still-active markers after past tense: "I had pain and it's getting worse"
+   → Flags as active despite past-tense opener.
+
+Returns:
+    TemporalSignal with:
+    - processed_text: cleaned text for model input
+    - is_active_emergency: True if active urgency detected despite temporal markers
+    - temporal_tag: "active" | "resolved" | "mixed" | "neutral"
+    - confidence: how confident the preprocessor is in its tag
+    - reason: human-readable explanation
+"""
+
+import re
+from dataclasses import dataclass, field
+from typing import Optional, List
+
+
+@dataclass
+class TemporalSignal:
+    """Result of temporal preprocessing."""
+    processed_text: str          # Text after preprocessing (may be modified)
+    original_text: str           # Original unmodified text
+    is_active_emergency: bool    # True if active urgency detected
+    temporal_tag: str            # "active" | "resolved" | "mixed" | "neutral"
+    confidence: float            # 0.0-1.0 confidence in the tag
+    reason: Optional[str] = None # Human-readable explanation
+    proxy_report: bool = False   # True if someone reporting for another person
+    matched_rules: List[str] = field(default_factory=list)
+
+
+# ── BUT-clause reversal patterns ──
+# These indicate the speaker HAD a resolved condition but it's NOW active again
+BUT_CLAUSE_PATTERNS = [
+    # "felt better but now..."
+    re.compile(
+        r"(?P<resolved>.+?)\b(?:but|however|except|although|though|yet)\b\s+"
+        r"(?P<active>(?:now|today|currently|right now|at this moment|this morning|tonight|again)"
+        r".+)",
+        re.IGNORECASE
+    ),
+    # "was fine but started..."
+    re.compile(
+        r"(?P<resolved>.+?)\b(?:but|however|except)\b\s+"
+        r"(?P<active>(?:it'?s?|the pain|the symptoms?|i'?m|i am|i feel|i have|it has|they)"
+        r"\s+(?:back|returned|worse|coming back|started|acting up|flaring).+)",
+        re.IGNORECASE
+    ),
+    # "...but now I can't..."
+    re.compile(
+        r"(?P<resolved>.+?)\b(?:but|however|except)\b\s+"
+        r"(?P<active>(?:now\s+)?i\s+(?:can'?t|cannot|am having|have|feel|'m).+)",
+        re.IGNORECASE
+    ),
+    # "...but then I started / but woke up with / but noticed..."
+    re.compile(
+        r"(?P<resolved>.+?)\b(?:but|however|except)\b\s+"
+        r"(?P<active>(?:then|woke up|noticed|started|began|suddenly|this morning)\b.+)",
+        re.IGNORECASE
+    ),
+]
+
+# ── General contrastive marker ──
+# Detects ANY contrastive clause to split and re-evaluate
+CONTRASTIVE_MARKER = re.compile(
+    r"\b(?:but|however|yet|still|though|although|except)\b",
+    re.IGNORECASE
+)
+
+# ── Still-active markers ──
+# If these appear AFTER past-tense language, the condition is STILL active
+STILL_ACTIVE_PATTERNS = [
+    re.compile(r"\b(?:still|again|keeps?|won'?t stop|getting worse|not getting better)\b", re.IGNORECASE),
+    re.compile(r"\b(?:came back|come back|coming back|returned|recurring|back again)\b", re.IGNORECASE),
+    re.compile(r"\b(?:right now|at this moment|currently|presently|as we speak)\b", re.IGNORECASE),
+    re.compile(r"\b(?:worse than|worse today|worse now|escalating|intensifying)\b", re.IGNORECASE),
+    re.compile(r"\b(?:i'?m (?:still |now )?(?:having|experiencing))\b", re.IGNORECASE),
+    re.compile(r"\bi'?m feeling\b(?!\s*(?:better|fine|good|okay|ok|great|alright|normal|well))", re.IGNORECASE),
+    re.compile(r"\b(?:it'?s (?:back|worse|not going away|spreading))\b", re.IGNORECASE),
+    re.compile(r"\b(?:hasn'?t (?:gone away|stopped|improved|gotten better))\b", re.IGNORECASE),
+]
+
+# ── Past-tense / resolved markers ──
+PAST_TENSE_PATTERNS = [
+    re.compile(r"\bi (?:had|used to have|was having|experienced|went through|suffered)\b", re.IGNORECASE),
+    re.compile(r"\b(?:last (?:week|month|year|night|time)|yesterday|\d+ (?:days?|weeks?|months?|years?) ago)\b", re.IGNORECASE),
+    re.compile(r"\b(?:in the past|previously|formerly|back in|when i was)\b", re.IGNORECASE),
+]
+
+RESOLVED_PATTERNS = [
+    re.compile(r"\b(?:feeling (?:much )?better|improved|resolved|went away|gone now)\b", re.IGNORECASE),
+    re.compile(r"\b(?:no longer|stopped|cleared up|fine now|okay now|recovered)\b", re.IGNORECASE),
+    re.compile(r"\b(?:been treated|got (?:it )?checked|under control|managed|stable)\b", re.IGNORECASE),
+    re.compile(r"\b(?:i'?m fine|i am fine|i'?m okay|i'?m ok|i'?m good|i'?m alright)\b", re.IGNORECASE),
+    re.compile(r"\b(?:checked (?:me |it )?out|doctor (?:checked|said|cleared)|all clear)\b", re.IGNORECASE),
+]
+
+# ── Proxy/third-party reporting patterns ──
+PROXY_PATTERNS = [
+    re.compile(
+        r"\b(?:my\s+)?(?:mom|mother|dad|father|wife|husband|son|daughter|child|kid|"
+        r"grandma|grandmother|grandpa|grandfather|brother|sister|friend|neighbor|"
+        r"partner|spouse|baby|toddler|infant)\b",
+        re.IGNORECASE
+    ),
+]
+
+# Active urgency markers that override third-party suppression
+PROXY_ACTIVE_URGENCY = [
+    re.compile(r"\b(?:says?|told me|telling me|texted|called|screaming)\b.*\b(?:hurts?|pain|can'?t breathe|bleeding|fell|fainted|passed out|unconscious|chest|heart|seizure)\b", re.IGNORECASE),
+    re.compile(r"\b(?:hurts?|pain|can'?t breathe|bleeding|fell|fainted|passed out|unconscious|chest|heart|seizure)\b.*\b(?:really|very|so|extremely|terribly|awful|bad)\b", re.IGNORECASE),
+    re.compile(r"\b(?:need|needs?|rush|hurry|emergency|ambulance|911|help)\b", re.IGNORECASE),
+    re.compile(r"\b(?:right now|just now|just happened|happening)\b", re.IGNORECASE),
+]
+
+# ── Intermittent/recurring symptom patterns ──
+# Ambiguous intermittent phrasing with dangerous symptoms should bias toward
+# escalation unless the patient's record shows chronic, stable baseline.
+INTERMITTENT_ACTIVE = [
+    re.compile(r"\b(?:sometimes|occasionally|on and off|comes and goes|every now and then|once in a while|from time to time|intermittent)\b.*\b(?:trouble breathing|chest pain|can'?t breathe|difficulty breathing|hard to breathe|dizzy|faint|pass out|black out|seizure|heart races|heart pounds|palpitation)\b", re.IGNORECASE),
+    re.compile(r"\b(?:trouble breathing|chest pain|can'?t breathe|difficulty breathing|hard to breathe|dizzy|faint|pass out|black out|seizure|heart races|heart pounds|palpitation)\b.*\b(?:sometimes|occasionally|on and off|comes and goes|every now and then|once in a while|from time to time|intermittent)\b", re.IGNORECASE),
+    re.compile(r"\b(?:sometimes|occasionally|on and off|every now and then)\b.*\b(?:pain in my chest|pressure in my chest|tightness in my chest|left arm goes numb|vision goes|lose consciousness|feel like i.{0,10}(?:faint|pass out))\b", re.IGNORECASE),
+]
+
+
+def preprocess_temporal(text: str, context: Optional[str] = None) -> TemporalSignal:
+    """
+    Analyze and preprocess text for temporal context before ML classification.
+    
+    This is the main entry point. Call this BEFORE tokenization/inference.
+    
+    Args:
+        text: Patient's current utterance
+        context: Optional conversation history
+        
+    Returns:
+        TemporalSignal with preprocessing results
+    """
+    original = text
+    matched_rules = []
+    
+    # ── Step 1: Check for BUT-clause reversals ──
+    for i, pattern in enumerate(BUT_CLAUSE_PATTERNS):
+        m = pattern.search(text)
+        if m:
+            active_part = m.group("active").strip()
+            if len(active_part) >= 10:  # Sanity check: active part is meaningful
+                matched_rules.append(f"but_clause_reversal_{i}")
+                return TemporalSignal(
+                    processed_text=active_part,
+                    original_text=original,
+                    is_active_emergency=True,
+                    temporal_tag="active",
+                    confidence=0.90,
+                    reason=f"BUT-clause reversal detected: resolved prefix discarded, active complaint extracted: '{active_part[:60]}'",
+                    matched_rules=matched_rules,
+                )
+    
+    # ── Step 2: Check for proxy/third-party with active urgency ──
+    is_proxy = any(p.search(text) for p in PROXY_PATTERNS)
+    if is_proxy:
+        has_active_urgency = any(p.search(text) for p in PROXY_ACTIVE_URGENCY)
+        if has_active_urgency:
+            matched_rules.append("proxy_active_urgency")
+            return TemporalSignal(
+                processed_text=text,
+                original_text=original,
+                is_active_emergency=True,
+                temporal_tag="active",
+                confidence=0.85,
+                reason="Third-party report with active urgency — treat as emergency",
+                proxy_report=True,
+                matched_rules=matched_rules,
+            )
+    
+    # ── Step 3: Check for intermittent symptoms with dangerous conditions ──
+    # Moved BEFORE past-tense analysis: "sometimes I have chest pain" should
+    # bias toward escalation regardless of temporal framing.
+    for p in INTERMITTENT_ACTIVE:
+        if p.search(text):
+            matched_rules.append("intermittent_dangerous")
+            return TemporalSignal(
+                processed_text=text,
+                original_text=original,
+                is_active_emergency=True,
+                temporal_tag="active",
+                confidence=0.75,
+                reason="Intermittent/recurring dangerous symptom — should escalate",
+                matched_rules=matched_rules,
+            )
+
+    # ── Step 4: Check for past-tense + still-active markers ──
+    has_past = any(p.search(text) for p in PAST_TENSE_PATTERNS)
+    has_still_active = any(p.search(text) for p in STILL_ACTIVE_PATTERNS)
+    has_resolved = any(p.search(text) for p in RESOLVED_PATTERNS)
+
+    if has_past and has_still_active:
+        matched_rules.append("past_but_still_active")
+        return TemporalSignal(
+            processed_text=text,
+            original_text=original,
+            is_active_emergency=True,
+            temporal_tag="active",
+            confidence=0.85,
+            reason="Past-tense language detected BUT still-active markers present — active condition",
+            matched_rules=matched_rules,
+        )
+
+    # ── Step 5: Contrastive clause analysis ──
+    # When but/however/yet splits a sentence, prioritize the post-contrastive
+    # clause — contrast often reverses clinical polarity.
+    contrastive_match = CONTRASTIVE_MARKER.search(text)
+    if contrastive_match and has_past:
+        post_contrastive = text[contrastive_match.end():].strip()
+        # Check if post-contrastive clause contains resolution markers
+        post_has_resolved = any(p.search(post_contrastive) for p in RESOLVED_PATTERNS)
+        # Check if post-contrastive clause contains active markers
+        post_has_active = any(p.search(post_contrastive) for p in STILL_ACTIVE_PATTERNS)
+
+        if post_has_active and not post_has_resolved:
+            # "I had chest pain yesterday but it's getting worse" → active
+            matched_rules.append("contrastive_post_active")
+            return TemporalSignal(
+                processed_text=text,
+                original_text=original,
+                is_active_emergency=True,
+                temporal_tag="active",
+                confidence=0.90,
+                reason=f"Contrastive clause reversal: post-contrastive is active — '{post_contrastive[:50]}'",
+                matched_rules=matched_rules,
+            )
+
+        if post_has_resolved and not post_has_active:
+            # "I had chest pain yesterday but I'm feeling better now"
+            # → resolved, but app.py enforces R2 minimum for R3 domains
+            matched_rules.append("contrastive_post_resolved")
+            return TemporalSignal(
+                processed_text=text,
+                original_text=original,
+                is_active_emergency=False,
+                temporal_tag="resolved",
+                confidence=0.80,
+                reason="Past symptom with contrastive resolution — resolved but warrants clinical follow-up",
+                matched_rules=matched_rules,
+            )
+
+    # ── Step 6: Past + explicit resolution (no contrastive) ──
+    if has_past and has_resolved and not has_still_active:
+        matched_rules.append("past_and_resolved")
+        return TemporalSignal(
+            processed_text=text,
+            original_text=original,
+            is_active_emergency=False,
+            temporal_tag="resolved",
+            confidence=0.80,
+            reason="Past-tense + resolution markers, no active signals — resolved but warrants follow-up",
+            matched_rules=matched_rules,
+        )
+
+    # ── Step 7: Past tense only — NO resolution evidence ──
+    # SAFETY: Past tense alone does NOT mean resolved. "I had chest pain
+    # yesterday" without saying they're better is a RED FLAG, not a reason
+    # to suppress. Tag as neutral and let the safety system handle it.
+    # Proxy reports are also NOT automatically suppressed — caregivers are
+    # authoritative reporters of acute symptoms.
+    if has_past and not has_still_active and not has_resolved:
+        matched_rules.append("past_no_resolution")
+        return TemporalSignal(
+            processed_text=text,
+            original_text=original,
+            is_active_emergency=False,
+            temporal_tag="neutral",
+            confidence=0.50,
+            reason="Past-tense language but NO resolution evidence — cannot confirm resolved",
+            proxy_report=is_proxy,
+            matched_rules=matched_rules,
+        )
+    
+    # ── Step 8: No temporal signals detected — neutral ──
+    return TemporalSignal(
+        processed_text=text,
+        original_text=original,
+        is_active_emergency=False,
+        temporal_tag="neutral",
+        confidence=0.5,
+        reason="No temporal signals detected",
+        matched_rules=matched_rules,
+    )
diff --git a/streaming_intent/__init__.py b/streaming_intent/__init__.py
new file mode 100644
index 0000000000000000000000000000000000000000..983c9a984e8085977a8e0ef6600aa9957c600ff7
--- /dev/null
+++ b/streaming_intent/__init__.py
@@ -0,0 +1,19 @@
+"""
+Streaming Intent Router Module
+
+HMM-style belief updating for processing STT chunks with stable intent decisions.
+"""
+
+from .tracker import StreamingIntentTracker, Decision, Chunk, DecisionMode
+from .belief import BeliefUpdater, EmissionTransform
+from .config import StreamingConfig
+
+__all__ = [
+    "StreamingIntentTracker",
+    "Decision",
+    "Chunk",
+    "DecisionMode",
+    "BeliefUpdater",
+    "EmissionTransform",
+    "StreamingConfig",
+]
diff --git a/streaming_intent/belief.py b/streaming_intent/belief.py
new file mode 100644
index 0000000000000000000000000000000000000000..48f2f2d7cfc4f9816a144f7836c28acd1487b4f8
--- /dev/null
+++ b/streaming_intent/belief.py
@@ -0,0 +1,300 @@
+"""
+HMM Belief Updater for streaming intent classification.
+
+Implements Markov filtering in LOG-SPACE for numerical stability:
+- Predict step: log_b_pred = logsumexp(log_T + log_b_prev)
+- Update step: log_b = log_b_pred + log_emission - logsumexp(...)
+
+Supports multiple emission transforms for ablation:
+- 'power': emission = (p + eps)^alpha (sharpening)
+- 'temperature': emission = softmax(logits / T)
+- 'isotonic': calibrated probabilities (requires calibrator)
+- 'raw': pass-through neural posteriors
+"""
+
+import numpy as np
+from enum import Enum
+from typing import Dict, Optional, Tuple, Callable
+from .config import StreamingConfig
+
+
+class EmissionTransform(Enum):
+    """Emission transform methods for ablation studies."""
+    POWER = "power"           # (p + eps)^alpha sharpening
+    TEMPERATURE = "temperature"  # softmax(logits / T)
+    RAW = "raw"               # Pass-through neural posteriors
+    ISOTONIC = "isotonic"     # Calibrated (requires external calibrator)
+
+
+def logsumexp(log_vec: np.ndarray) -> float:
+    """
+    Numerically stable log-sum-exp.
+    
+    Edge cases:
+    - If all values are -inf, returns -inf (empty probability mass)
+    - If any value is +inf, returns +inf (handles numerical overflow gracefully)
+    """
+    max_val = np.max(log_vec)
+    if np.isinf(max_val):
+        return max_val
+    return max_val + np.log(np.sum(np.exp(log_vec - max_val)))
+
+
+def log_normalize(log_vec: np.ndarray) -> np.ndarray:
+    """Normalize log-probabilities to sum to 1 in probability space."""
+    return log_vec - logsumexp(log_vec)
+
+
+class BeliefUpdater:
+    """
+    HMM-style belief state updater with log-space arithmetic.
+    
+    Maintains a probability distribution over intents and updates it
+    using transition dynamics and emission observations from neural model.
+    
+    All internal computations are done in log-space to prevent underflow
+    in long sequences. Probabilities are converted only for output.
+    
+    Supports ablation modes:
+    - use_hmm=False: Raw neural posteriors (no temporal smoothing)
+    - emission_transform: Different emission sharpening methods
+    """
+    
+    def __init__(
+        self,
+        config: StreamingConfig,
+        use_hmm: bool = True,
+        emission_transform: EmissionTransform = EmissionTransform.POWER,
+        isotonic_calibrator: Optional[Callable] = None,
+    ):
+        """
+        Initialize belief updater.
+        
+        Args:
+            config: Streaming configuration with intents, transitions, thresholds.
+            use_hmm: If False, bypass HMM and return raw neural posteriors.
+            emission_transform: Method for transforming neural outputs to emissions.
+            isotonic_calibrator: Optional calibrator function for ISOTONIC mode.
+        """
+        self.config = config
+        self.n_intents = len(config.intents)
+        self.use_hmm = use_hmm
+        self.emission_transform = emission_transform
+        self.isotonic_calibrator = isotonic_calibrator
+        
+        # Initialize log-space belief
+        prior = config.get_prior_vector()
+        self.log_belief = np.log(prior + config.epsilon)
+        self.log_belief = log_normalize(self.log_belief)
+        
+        # Pre-compute log transition matrix
+        self.log_T = np.log(config.transition_matrix + config.epsilon)
+        
+        self._step_count = 0
+        self._last_raw_probs: Optional[Dict[str, float]] = None
+    
+    def reset(self) -> None:
+        """Reset belief to prior distribution."""
+        prior = self.config.get_prior_vector()
+        self.log_belief = np.log(prior + self.config.epsilon)
+        self.log_belief = log_normalize(self.log_belief)
+        self._step_count = 0
+        self._last_raw_probs = None
+    
+    def predict(self) -> np.ndarray:
+        """
+        Prediction step in log-space: propagate belief through transition matrix.
+        
+        log_b_pred[j] = logsumexp_i(log_T[i,j] + log_b[i])
+        
+        Returns:
+            Log-space predicted belief state.
+        """
+        log_b_pred = np.zeros(self.n_intents)
+        for j in range(self.n_intents):
+            # Sum over all previous states i: T[i,j] * b[i]
+            log_terms = self.log_T[:, j] + self.log_belief
+            log_b_pred[j] = logsumexp(log_terms)
+        
+        return log_normalize(log_b_pred)
+    
+    def compute_log_emission(
+        self,
+        neural_probs: Dict[str, float],
+        logits: Optional[Dict[str, float]] = None,
+    ) -> np.ndarray:
+        """
+        Compute log-emission likelihood from neural network outputs.
+        
+        Supports multiple transform methods for ablation:
+        - POWER: log_emission = alpha * log(p + eps)
+        - TEMPERATURE: log_emission = logits / T - logsumexp(logits / T)
+        - RAW: log_emission = log(p + eps)
+        - ISOTONIC: log_emission = log(calibrate(p) + eps)
+        
+        Args:
+            neural_probs: Dict mapping intent names to probabilities.
+            logits: Optional dict of raw logits for temperature scaling.
+            
+        Returns:
+            Log-emission likelihood vector.
+        """
+        log_emission = np.full(self.n_intents, np.log(self.config.epsilon))
+        
+        if self.emission_transform == EmissionTransform.POWER:
+            # Power transform: sharpen probabilities
+            for intent, prob in neural_probs.items():
+                if intent in self.config.intent_to_idx:
+                    idx = self.config.intent_to_idx[intent]
+                    log_emission[idx] = self.config.alpha * np.log(prob + self.config.epsilon)
+        
+        elif self.emission_transform == EmissionTransform.TEMPERATURE:
+            # Temperature scaling on logits
+            if logits is None:
+                # Fallback: invert softmax approximately
+                logits = {k: np.log(v + self.config.epsilon) for k, v in neural_probs.items()}
+            
+            temp = self.config.temperature
+            scaled_logits = np.full(self.n_intents, -np.inf)
+            for intent, logit in logits.items():
+                if intent in self.config.intent_to_idx:
+                    idx = self.config.intent_to_idx[intent]
+                    scaled_logits[idx] = logit / temp
+            
+            log_emission = log_normalize(scaled_logits)
+        
+        elif self.emission_transform == EmissionTransform.RAW:
+            # Pass-through: no sharpening
+            for intent, prob in neural_probs.items():
+                if intent in self.config.intent_to_idx:
+                    idx = self.config.intent_to_idx[intent]
+                    log_emission[idx] = np.log(prob + self.config.epsilon)
+        
+        elif self.emission_transform == EmissionTransform.ISOTONIC:
+            # Isotonic calibration
+            if self.isotonic_calibrator is not None:
+                calibrated = self.isotonic_calibrator(neural_probs)
+                for intent, prob in calibrated.items():
+                    if intent in self.config.intent_to_idx:
+                        idx = self.config.intent_to_idx[intent]
+                        log_emission[idx] = np.log(prob + self.config.epsilon)
+            else:
+                # Fallback to raw if no calibrator
+                for intent, prob in neural_probs.items():
+                    if intent in self.config.intent_to_idx:
+                        idx = self.config.intent_to_idx[intent]
+                        log_emission[idx] = np.log(prob + self.config.epsilon)
+        
+        return log_emission
+    
+    def update(
+        self,
+        neural_probs: Dict[str, float],
+        logits: Optional[Dict[str, float]] = None,
+    ) -> np.ndarray:
+        """
+        Full belief update in log-space.
+        
+        If use_hmm=True:
+            1. log_b_pred = predict() (transition dynamics)
+            2. log_emission = compute_log_emission(neural_probs)
+            3. log_b = normalize(log_b_pred + log_emission)
+        
+        If use_hmm=False (ablation mode):
+            Directly use neural posteriors as belief.
+        
+        Args:
+            neural_probs: Dict mapping intent names to probabilities from neural model.
+            logits: Optional dict of raw logits for temperature scaling.
+            
+        Returns:
+            Updated belief state (in probability space).
+        """
+        self._last_raw_probs = neural_probs.copy()
+        
+        if not self.use_hmm:
+            # Ablation: bypass HMM, use raw neural posteriors
+            for intent, prob in neural_probs.items():
+                if intent in self.config.intent_to_idx:
+                    idx = self.config.intent_to_idx[intent]
+                    self.log_belief[idx] = np.log(prob + self.config.epsilon)
+            self.log_belief = log_normalize(self.log_belief)
+            self._step_count += 1
+            return self.belief
+        
+        # Predict step
+        log_b_pred = self.predict()
+        
+        # Compute log-emission likelihood
+        log_emission = self.compute_log_emission(neural_probs, logits)
+        
+        # Update step: element-wise addition in log-space and normalize
+        log_b_updated = log_b_pred + log_emission
+        self.log_belief = log_normalize(log_b_updated)
+        self._step_count += 1
+        
+        return self.belief
+    
+    def update_with_log_emission(self, log_emission: np.ndarray) -> np.ndarray:
+        """
+        Update belief with pre-computed log-emission vector.
+        
+        Args:
+            log_emission: Pre-computed log-emission likelihood vector.
+            
+        Returns:
+            Updated belief state (in probability space).
+        """
+        if not self.use_hmm:
+            self.log_belief = log_normalize(log_emission)
+            self._step_count += 1
+            return self.belief
+        
+        log_b_pred = self.predict()
+        log_b_updated = log_b_pred + log_emission
+        self.log_belief = log_normalize(log_b_updated)
+        self._step_count += 1
+        return self.belief
+    
+    @property
+    def belief(self) -> np.ndarray:
+        """Get current belief in probability space."""
+        return np.exp(self.log_belief)
+    
+    def get_belief_dict(self) -> Dict[str, float]:
+        """Get current belief as dictionary."""
+        probs = self.belief
+        return {
+            self.config.idx_to_intent[i]: float(probs[i])
+            for i in range(self.n_intents)
+        }
+    
+    def get_top_intent(self) -> Tuple[str, float]:
+        """Get intent with highest belief probability."""
+        probs = self.belief
+        idx = int(np.argmax(probs))
+        return self.config.idx_to_intent[idx], float(probs[idx])
+    
+    def get_intent_prob(self, intent: str) -> float:
+        """Get belief probability for specific intent."""
+        if intent in self.config.intent_to_idx:
+            idx = self.config.intent_to_idx[intent]
+            return float(np.exp(self.log_belief[idx]))
+        return 0.0
+    
+    def get_log_belief(self) -> np.ndarray:
+        """Get current log-belief (for debugging/analysis)."""
+        return self.log_belief.copy()
+    
+    def get_last_raw_probs(self) -> Optional[Dict[str, float]]:
+        """Get last raw neural probabilities (before HMM filtering)."""
+        return self._last_raw_probs
+    
+    @property
+    def step_count(self) -> int:
+        """Number of update steps performed."""
+        return self._step_count
+    
+    def is_normalized(self, tol: float = 1e-6) -> bool:
+        """Check if belief state is properly normalized."""
+        return abs(self.belief.sum() - 1.0) < tol
diff --git a/streaming_intent/config.py b/streaming_intent/config.py
new file mode 100644
index 0000000000000000000000000000000000000000..d54f52cbb1d33322496869edfbd277db4884a7e7
--- /dev/null
+++ b/streaming_intent/config.py
@@ -0,0 +1,172 @@
+"""
+Configuration loader for streaming intent router.
+"""
+
+import os
+from pathlib import Path
+from typing import Dict, List, Optional
+from dataclasses import dataclass, field
+
+import yaml
+import numpy as np
+
+
+@dataclass
+class StreamingConfig:
+    """Configuration for streaming intent router."""
+    
+    intents: List[str] = field(default_factory=list)
+    prior: Dict[str, float] = field(default_factory=dict)
+    transition_matrix: np.ndarray = field(default_factory=lambda: np.array([]))
+    intent_to_idx: Dict[str, int] = field(default_factory=dict)
+    idx_to_intent: Dict[int, str] = field(default_factory=dict)
+    
+    # Emission parameters
+    alpha: float = 1.5
+    epsilon: float = 1e-8
+    
+    # Decision thresholds
+    theta_hi: float = 0.85
+    theta_med: float = 0.60
+    theta_lock: float = 0.70
+    K: int = 3
+    
+    # Window parameters
+    max_tokens: int = 64
+    max_tokens_limit: int = 128
+    
+    # Debounce parameters
+    debounce_ms: int = 150
+    min_change_chars: int = 3
+    
+    # Model parameters
+    model_max_length: int = 48
+    
+    # Emission temperature (for temperature scaling transform)
+    temperature: float = 1.0
+    
+    # SPRT parameters
+    sprt_alpha: float = 0.05
+    sprt_beta: float = 0.10
+    sprt_p0: float = 0.20
+    sprt_p1: float = 0.60
+    
+    @classmethod
+    def from_yaml(cls, path: Optional[str] = None) -> "StreamingConfig":
+        """Load configuration from YAML file."""
+        if path is None:
+            path = Path(__file__).parent.parent / "config" / "streaming_intent.yaml"
+        
+        with open(path, "r") as f:
+            data = yaml.safe_load(f)
+        
+        config = cls()
+        config.intents = data.get("intents", [])
+        config.prior = data.get("prior", {})
+        
+        # Build intent index mappings
+        config.intent_to_idx = {intent: i for i, intent in enumerate(config.intents)}
+        config.idx_to_intent = {i: intent for i, intent in enumerate(config.intents)}
+        
+        # Build transition matrix as numpy array
+        n = len(config.intents)
+        config.transition_matrix = np.zeros((n, n))
+        trans_dict = data.get("transition_matrix", {})
+        for from_intent, to_probs in trans_dict.items():
+            if from_intent in config.intent_to_idx:
+                i = config.intent_to_idx[from_intent]
+                for to_intent, prob in to_probs.items():
+                    if to_intent in config.intent_to_idx:
+                        j = config.intent_to_idx[to_intent]
+                        config.transition_matrix[i, j] = prob
+        
+        # Normalize rows (ensure they sum to 1)
+        row_sums = config.transition_matrix.sum(axis=1, keepdims=True)
+        row_sums[row_sums == 0] = 1  # Avoid division by zero
+        config.transition_matrix = config.transition_matrix / row_sums
+        
+        # Emission parameters
+        emission = data.get("emission", {})
+        config.alpha = emission.get("alpha", 1.5)
+        config.epsilon = emission.get("epsilon", 1e-8)
+        
+        # Decision thresholds
+        thresholds = data.get("thresholds", {})
+        config.theta_hi = thresholds.get("theta_hi", 0.85)
+        config.theta_med = thresholds.get("theta_med", 0.60)
+        config.theta_lock = thresholds.get("theta_lock", 0.70)
+        config.K = thresholds.get("K", 3)
+        
+        # Window parameters
+        window = data.get("window", {})
+        config.max_tokens = window.get("max_tokens", 64)
+        config.max_tokens_limit = window.get("max_tokens_limit", 128)
+        
+        # Debounce parameters
+        debounce = data.get("debounce", {})
+        config.debounce_ms = debounce.get("debounce_ms", 150)
+        config.min_change_chars = debounce.get("min_change_chars", 3)
+        
+        # Model parameters
+        model = data.get("model", {})
+        config.model_max_length = model.get("max_length", 64)
+        
+        # SPRT parameters
+        sprt = data.get("sprt", {})
+        config.sprt_alpha = sprt.get("alpha", 0.05)
+        config.sprt_beta = sprt.get("beta", 0.10)
+        config.sprt_p0 = sprt.get("p0", 0.20)
+        config.sprt_p1 = sprt.get("p1", 0.60)
+        
+        # Emission temperature
+        config.temperature = emission.get("temperature", 1.0)
+        
+        # Validate configuration
+        if not config.intents:
+            raise ValueError(
+                f"No intents found in config file: {path}. "
+                "The 'intents' list must contain at least one intent."
+            )
+        
+        return config
+    
+    def get_prior_vector(self) -> np.ndarray:
+        """Get prior distribution as numpy array."""
+        if not self.intents:
+            raise ValueError(
+                "Cannot compute prior vector: intents list is empty. "
+                "Ensure streaming_intent.yaml contains valid intent definitions."
+            )
+        
+        prior = np.zeros(len(self.intents))
+        for intent, prob in self.prior.items():
+            if intent in self.intent_to_idx:
+                prior[self.intent_to_idx[intent]] = prob
+        
+        # Normalize
+        if prior.sum() > 0:
+            prior = prior / prior.sum()
+        else:
+            # Fallback to uniform distribution
+            prior = np.ones(len(self.intents)) / len(self.intents)
+        return prior
+    
+    def save_transition_matrix(self, path: Optional[str] = None) -> None:
+        """Save current transition matrix back to config file."""
+        if path is None:
+            path = Path(__file__).parent.parent / "config" / "streaming_intent.yaml"
+        
+        with open(path, "r") as f:
+            data = yaml.safe_load(f)
+        
+        # Update transition matrix in data
+        trans_dict = {}
+        for i, from_intent in enumerate(self.intents):
+            trans_dict[from_intent] = {}
+            for j, to_intent in enumerate(self.intents):
+                trans_dict[from_intent][to_intent] = float(self.transition_matrix[i, j])
+        
+        data["transition_matrix"] = trans_dict
+        
+        with open(path, "w") as f:
+            yaml.dump(data, f, default_flow_style=False, sort_keys=False)
diff --git a/streaming_intent/metrics.py b/streaming_intent/metrics.py
new file mode 100644
index 0000000000000000000000000000000000000000..c97aa950d50dbc4993e691b547c965ccab0a9f7e
--- /dev/null
+++ b/streaming_intent/metrics.py
@@ -0,0 +1,196 @@
+"""
+Metrics counters for streaming intent tracking.
+
+Tracks escalation frequency, gray zone hits, decision timing, and near-misses.
+Thread-safe for use in concurrent request handling.
+
+Near-miss tracking:
+- Cases where escalation probability exceeded threshold but never committed
+- Critical for operational monitoring and safety validation
+"""
+
+import threading
+import time
+import numpy as np
+from dataclasses import dataclass, field
+from typing import Dict, Any, List, Optional, Tuple
+from collections import defaultdict
+
+
+@dataclass
+class MetricsCounter:
+    """
+    Thread-safe metrics tracking for streaming intent router.
+    
+    Tracks:
+    - Total steps processed
+    - Escalation count and rate
+    - Gray zone hits (neither escalate nor commit)
+    - Average steps to decision
+    - Intent commitment distribution
+    - Time-to-escalation distribution (percentiles)
+    - Near-miss rate and peak probabilities
+    """
+    
+    total_steps: int = 0
+    escalation_count: int = 0
+    gray_zone_count: int = 0
+    commitment_count: int = 0
+    commitment_by_intent: Dict[str, int] = field(default_factory=lambda: defaultdict(int))
+    steps_to_escalation: List[int] = field(default_factory=list)
+    steps_to_commitment: List[int] = field(default_factory=list)
+    _current_session_steps: int = 0
+    _session_count: int = 0
+    _lock: threading.Lock = field(default_factory=threading.Lock)
+    
+    # Near-miss tracking
+    near_miss_count: int = 0
+    near_miss_peak_probs: List[float] = field(default_factory=list)
+    
+    # Time-to-escalation in milliseconds (for distribution analysis)
+    escalation_latencies_ms: List[float] = field(default_factory=list)
+    _session_start_time_ms: float = 0.0
+    
+    def record_step(self) -> None:
+        """Record a processing step (thread-safe)."""
+        with self._lock:
+            self.total_steps += 1
+            self._current_session_steps += 1
+    
+    def record_escalation(self) -> None:
+        """Record an escalation event (thread-safe)."""
+        with self._lock:
+            self.escalation_count += 1
+            self.steps_to_escalation.append(self._current_session_steps)
+            
+            # Record time-to-escalation
+            if self._session_start_time_ms > 0:
+                latency_ms = time.time() * 1000 - self._session_start_time_ms
+                self.escalation_latencies_ms.append(latency_ms)
+    
+    def record_commitment(self, intent: str) -> None:
+        """Record an intent commitment (thread-safe)."""
+        with self._lock:
+            self.commitment_count += 1
+            self.commitment_by_intent[intent] += 1
+            self.steps_to_commitment.append(self._current_session_steps)
+    
+    def record_gray_zone(self) -> None:
+        """Record a gray zone hit (no decision made) (thread-safe)."""
+        with self._lock:
+            self.gray_zone_count += 1
+    
+    def record_near_miss(self, peak_prob: float) -> None:
+        """
+        Record a near-miss event (thread-safe).
+        
+        A near-miss is when escalation probability exceeded threshold
+        at some point but escalation was never triggered.
+        
+        Args:
+            peak_prob: Peak escalation probability observed in session.
+        """
+        with self._lock:
+            self.near_miss_count += 1
+            self.near_miss_peak_probs.append(peak_prob)
+    
+    def start_session(self) -> None:
+        """Start a new tracking session (thread-safe)."""
+        with self._lock:
+            self._current_session_steps = 0
+            self._session_count += 1
+            self._session_start_time_ms = time.time() * 1000
+    
+    def reset(self) -> None:
+        """Reset all counters (thread-safe)."""
+        with self._lock:
+            self.total_steps = 0
+            self.escalation_count = 0
+            self.gray_zone_count = 0
+            self.commitment_count = 0
+            self.commitment_by_intent = defaultdict(int)
+            self.steps_to_escalation = []
+            self.steps_to_commitment = []
+            self._current_session_steps = 0
+            self._session_count = 0
+            # Reset near-miss tracking
+            self.near_miss_count = 0
+            self.near_miss_peak_probs = []
+            # Reset time-to-escalation tracking
+            self.escalation_latencies_ms = []
+            self._session_start_time_ms = 0.0
+    
+    def _compute_percentiles(self, data: List[float], percentiles: Optional[List[int]] = None) -> Dict[str, float]:
+        """Compute percentiles for a list of values."""
+        if percentiles is None:
+            percentiles = [50, 90, 95, 99]
+        if not data:
+            return {f"p{p}": 0.0 for p in percentiles}
+        arr = np.array(data)
+        return {f"p{p}": float(np.percentile(arr, p)) for p in percentiles}
+    
+    def get_summary(self) -> Dict[str, Any]:
+        """Get metrics summary (thread-safe)."""
+        with self._lock:
+            total_decisions = self.escalation_count + self.commitment_count
+            
+            avg_steps_to_escalation = (
+                sum(self.steps_to_escalation) / len(self.steps_to_escalation)
+                if self.steps_to_escalation else 0.0
+            )
+            avg_steps_to_commitment = (
+                sum(self.steps_to_commitment) / len(self.steps_to_commitment)
+                if self.steps_to_commitment else 0.0
+            )
+            
+            # Time-to-escalation distribution
+            escalation_latency_distribution = self._compute_percentiles(
+                self.escalation_latencies_ms
+            )
+            
+            # Near-miss statistics
+            near_miss_rate = (
+                self.near_miss_count / self._session_count 
+                if self._session_count > 0 else 0.0
+            )
+            avg_near_miss_peak = (
+                sum(self.near_miss_peak_probs) / len(self.near_miss_peak_probs)
+                if self.near_miss_peak_probs else 0.0
+            )
+            
+            return {
+                "total_steps": self.total_steps,
+                "total_sessions": self._session_count,
+                "escalation_count": self.escalation_count,
+                "escalation_rate": (
+                    self.escalation_count / total_decisions if total_decisions > 0 else 0.0
+                ),
+                "commitment_count": self.commitment_count,
+                "commitment_by_intent": dict(self.commitment_by_intent),
+                "gray_zone_count": self.gray_zone_count,
+                "gray_zone_rate": (
+                    self.gray_zone_count / self.total_steps if self.total_steps > 0 else 0.0
+                ),
+                "avg_steps_to_escalation": avg_steps_to_escalation,
+                "avg_steps_to_commitment": avg_steps_to_commitment,
+                "avg_steps_to_decision": (
+                    (sum(self.steps_to_escalation) + sum(self.steps_to_commitment)) /
+                    max(1, len(self.steps_to_escalation) + len(self.steps_to_commitment))
+                ),
+                # Time-to-escalation distribution (ms)
+                "escalation_latency_ms": escalation_latency_distribution,
+                # Near-miss metrics
+                "near_miss_count": self.near_miss_count,
+                "near_miss_rate": near_miss_rate,
+                "near_miss_avg_peak_prob": avg_near_miss_peak,
+            }
+    
+    def __repr__(self) -> str:
+        summary = self.get_summary()
+        return (
+            f"MetricsCounter("
+            f"steps={summary['total_steps']}, "
+            f"escalations={summary['escalation_count']}, "
+            f"commitments={summary['commitment_count']}, "
+            f"gray_zone={summary['gray_zone_count']})"
+        )
diff --git a/streaming_intent/tracker.py b/streaming_intent/tracker.py
new file mode 100644
index 0000000000000000000000000000000000000000..b607e39a7400cd6546e0fc31eb064558d0da4154
--- /dev/null
+++ b/streaming_intent/tracker.py
@@ -0,0 +1,510 @@
+"""
+Streaming Intent Tracker with HMM belief updating and SPRT stopping rules.
+
+Maintains rolling text window, debounce logic, and statistically-principled
+decision rules using Sequential Probability Ratio Test (SPRT).
+
+Key features:
+- Log-space HMM belief filtering (numerical stability)
+- SPRT-based escalation decisions (explicit error rate bounds)
+- Near-miss tracking for operational monitoring
+- Ablation support for comparing decision strategies
+"""
+
+import time
+import math
+from dataclasses import dataclass, field
+from typing import Dict, List, Optional, Callable, Any, Tuple
+from collections import deque
+from enum import Enum
+
+import numpy as np
+
+from .config import StreamingConfig
+from .belief import BeliefUpdater, EmissionTransform
+from .metrics import MetricsCounter
+
+
+class DecisionMode(Enum):
+    """Decision rule strategies for ablation studies."""
+    K_CONSECUTIVE = "k_consecutive"  # Original: K steps above threshold
+    SPRT = "sprt"                    # Sequential Probability Ratio Test
+    HYBRID = "hybrid"                # SPRT + K-consecutive fallback
+
+
+@dataclass
+class Chunk:
+    """Input chunk from STT system."""
+    text: str
+    is_final: bool = False
+    timestamp_ms: Optional[int] = None
+
+
+@dataclass
+class Decision:
+    """Output decision from tracker."""
+    current_belief: Dict[str, float]
+    top_intent: str
+    top_intent_prob: float
+    should_escalate: bool
+    should_commit: bool
+    committed_intent: Optional[str]
+    escalation_reason: Optional[str] = None
+    step_latency_ms: float = 0.0
+    step_count: int = 0
+    window_text: str = ""
+    # SPRT diagnostics
+    sprt_llr: Optional[float] = None  # Log-likelihood ratio
+    sprt_upper_bound: Optional[float] = None  # Upper decision boundary
+    sprt_lower_bound: Optional[float] = None  # Lower decision boundary
+
+
+class StreamingIntentTracker:
+    """
+    Streaming intent classifier with HMM-style belief updating and SPRT decisions.
+    
+    Features:
+    - Rolling window of recent text (max_tokens configurable)
+    - Debounce logic to prevent thrashing on partial updates
+    - SPRT-based decision rules with explicit error rate bounds
+    - Near-miss tracking for operational monitoring
+    - Ablation support (use_hmm, decision_mode, emission_transform)
+    
+    SPRT (Sequential Probability Ratio Test):
+        Tests H0: P(ESCALATION) = p0 vs H1: P(ESCALATION) = p1
+        - Upper boundary A = log((1-beta)/alpha) → decide H1 (escalate)
+        - Lower boundary B = log(beta/(1-alpha)) → decide H0 (don't escalate)
+        - Continue if B < LLR < A
+    
+    Usage:
+        tracker = StreamingIntentTracker(model_fn=my_inference)
+        
+        for chunk in stt_stream:
+            decision = tracker.update(chunk)
+            if decision.should_escalate:
+                handle_escalation()
+            elif decision.should_commit:
+                handle_intent(decision.committed_intent)
+    """
+    
+    def __init__(
+        self,
+        config: Optional[StreamingConfig] = None,
+        model_fn: Optional[Callable[[str], Dict[str, float]]] = None,
+        config_path: Optional[str] = None,
+        use_hmm: bool = True,
+        decision_mode: DecisionMode = DecisionMode.HYBRID,
+        emission_transform: EmissionTransform = EmissionTransform.POWER,
+        # SPRT parameter overrides (None = use config values)
+        sprt_alpha: Optional[float] = None,
+        sprt_beta: Optional[float] = None,
+        sprt_p0: Optional[float] = None,
+        sprt_p1: Optional[float] = None,
+    ):
+        """
+        Initialize streaming intent tracker.
+        
+        Args:
+            config: StreamingConfig instance (loads default if None)
+            model_fn: Function that takes text and returns intent probabilities.
+            config_path: Path to config YAML (used if config is None)
+            use_hmm: If False, bypass HMM filtering (ablation mode).
+            decision_mode: K_CONSECUTIVE, SPRT, or HYBRID.
+            emission_transform: How to transform neural outputs.
+            sprt_alpha: Target false escalation rate (overrides config).
+            sprt_beta: Target missed escalation rate (overrides config).
+            sprt_p0: Null hypothesis escalation probability (overrides config).
+            sprt_p1: Alternative hypothesis escalation probability (overrides config).
+        """
+        if config is None:
+            self.config = StreamingConfig.from_yaml(config_path)
+        else:
+            self.config = config
+        
+        self.model_fn = model_fn
+        self.use_hmm = use_hmm
+        self.decision_mode = decision_mode
+        
+        # Initialize belief updater with ablation options
+        self.belief_updater = BeliefUpdater(
+            self.config,
+            use_hmm=use_hmm,
+            emission_transform=emission_transform,
+        )
+        self.metrics = MetricsCounter()
+        
+        # SPRT parameters (use config values, allow overrides)
+        self.sprt_alpha = sprt_alpha if sprt_alpha is not None else self.config.sprt_alpha
+        self.sprt_beta = sprt_beta if sprt_beta is not None else self.config.sprt_beta
+        self.sprt_p0 = sprt_p0 if sprt_p0 is not None else self.config.sprt_p0
+        self.sprt_p1 = sprt_p1 if sprt_p1 is not None else self.config.sprt_p1
+        
+        # Compute SPRT boundaries (Wald's approximation)
+        # A = log((1-beta)/alpha) - upper boundary → escalate
+        # B = log(beta/(1-alpha)) - lower boundary → don't escalate
+        self.sprt_upper_bound = math.log((1 - self.sprt_beta) / self.sprt_alpha)
+        self.sprt_lower_bound = math.log(self.sprt_beta / (1 - self.sprt_alpha))
+        
+        # State
+        self._text_buffer: List[str] = []
+        self._window_text: str = ""
+        self._top_intent_history: deque = deque(maxlen=self.config.K + 5)
+        self._escalation_history: deque = deque(maxlen=self.config.K + 5)
+        self._last_update_ms: int = 0
+        self._last_text_hash: int = 0
+        self._committed: bool = False
+        self._committed_intent: Optional[str] = None
+        self._escalated: bool = False
+        
+        # SPRT state
+        self._sprt_llr: float = 0.0  # Cumulative log-likelihood ratio
+        
+        # Near-miss tracking
+        self._peak_escalation_prob: float = 0.0
+        self._near_miss_threshold: float = self.config.theta_med
+    
+    def reset(self) -> None:
+        """Reset tracker state for new conversation."""
+        # Track near-miss BEFORE reset (only if we actually processed data)
+        had_data = self.belief_updater.step_count > 0
+        if had_data:
+            if self._peak_escalation_prob >= self._near_miss_threshold and not self._escalated:
+                self.metrics.record_near_miss(self._peak_escalation_prob)
+        
+        # Now reset all state
+        self.belief_updater.reset()
+        self._text_buffer = []
+        self._window_text = ""
+        self._top_intent_history.clear()
+        self._escalation_history.clear()
+        self._last_update_ms = 0
+        self._last_text_hash = 0
+        self._committed = False
+        self._committed_intent = None
+        self._escalated = False
+        
+        # Reset SPRT state
+        self._sprt_llr = 0.0
+        self._peak_escalation_prob = 0.0
+        
+        self.metrics.start_session()
+    
+    def update(self, chunk: Chunk) -> Decision:
+        """
+        Process a chunk and return decision.
+        
+        Args:
+            chunk: Input chunk with text, is_final flag, and optional timestamp.
+            
+        Returns:
+            Decision with current belief, escalation status, and commitment status.
+        """
+        start_time = time.perf_counter()
+        
+        # Get current timestamp
+        current_ms = chunk.timestamp_ms or int(time.time() * 1000)
+        
+        # Check debounce conditions
+        if not self._should_update(chunk, current_ms):
+            # Return current state without update
+            top_intent, top_prob = self.belief_updater.get_top_intent()
+            return Decision(
+                current_belief=self.belief_updater.get_belief_dict(),
+                top_intent=top_intent,
+                top_intent_prob=top_prob,
+                should_escalate=self._escalated,
+                should_commit=self._committed,
+                committed_intent=self._committed_intent,
+                step_latency_ms=0.0,
+                step_count=self.belief_updater.step_count,
+                window_text=self._window_text,
+            )
+        
+        # Update text buffer and window
+        self._update_text_buffer(chunk)
+        
+        # Run model inference
+        if self.model_fn is None:
+            raise ValueError("model_fn must be set before calling update()")
+        
+        drivehealthbert_probs = self.model_fn(self._window_text)
+        
+        # Update belief state
+        self.belief_updater.update(drivehealthbert_probs)
+        
+        # Track history
+        top_intent, top_prob = self.belief_updater.get_top_intent()
+        self._top_intent_history.append(top_intent)
+        
+        escalation_prob = self.belief_updater.get_intent_prob("ESCALATION")
+        self._escalation_history.append(escalation_prob)
+        
+        # Update timestamps
+        self._last_update_ms = current_ms
+        self._last_text_hash = hash(self._window_text)
+        
+        # Make decisions
+        should_escalate, escalation_reason = self._check_escalation()
+        should_commit, committed_intent = self._check_commitment(top_intent, top_prob)
+        
+        # Update metrics
+        self.metrics.record_step()
+        if should_escalate and not self._escalated:
+            self.metrics.record_escalation()
+            self._escalated = True
+        if should_commit and not self._committed:
+            self.metrics.record_commitment(committed_intent)
+            self._committed = True
+            self._committed_intent = committed_intent
+        
+        # Check gray zone
+        if not should_escalate and not should_commit:
+            self.metrics.record_gray_zone()
+        
+        elapsed_ms = (time.perf_counter() - start_time) * 1000
+        
+        return Decision(
+            current_belief=self.belief_updater.get_belief_dict(),
+            top_intent=top_intent,
+            top_intent_prob=top_prob,
+            should_escalate=should_escalate or self._escalated,
+            should_commit=should_commit or self._committed,
+            committed_intent=self._committed_intent if (should_commit or self._committed) else None,
+            escalation_reason=escalation_reason,
+            step_latency_ms=elapsed_ms,
+            step_count=self.belief_updater.step_count,
+            window_text=self._window_text,
+            # SPRT diagnostics
+            sprt_llr=self._sprt_llr,
+            sprt_upper_bound=self.sprt_upper_bound,
+            sprt_lower_bound=self.sprt_lower_bound,
+        )
+    
+    def _should_update(self, chunk: Chunk, current_ms: int) -> bool:
+        """Check if we should process this chunk (debounce logic)."""
+        # Always update on final segments
+        if chunk.is_final:
+            return True
+        
+        # Check time-based debounce
+        elapsed = current_ms - self._last_update_ms
+        if elapsed < self.config.debounce_ms:
+            return False
+        
+        # Check if text changed significantly
+        new_text = self._compute_window_text(chunk.text)
+        text_change = abs(len(new_text) - len(self._window_text))
+        if text_change < self.config.min_change_chars:
+            # Also check hash for content changes
+            if hash(new_text) == self._last_text_hash:
+                return False
+        
+        return True
+    
+    def _update_text_buffer(self, chunk: Chunk) -> None:
+        """Update text buffer and compute rolling window."""
+        if chunk.is_final:
+            # Final segment - append to buffer
+            self._text_buffer.append(chunk.text)
+        else:
+            # Partial - replace last entry if buffer not empty, otherwise append
+            if self._text_buffer:
+                self._text_buffer[-1] = chunk.text
+            else:
+                self._text_buffer.append(chunk.text)
+        
+        self._window_text = self._compute_window_text()
+    
+    def _compute_window_text(self, pending_text: str = "") -> str:
+        """Compute rolling window text (last N tokens)."""
+        # Combine buffer with pending text
+        full_text = " ".join(self._text_buffer)
+        if pending_text:
+            full_text = full_text + " " + pending_text if full_text else pending_text
+        
+        # Simple token approximation: split on whitespace
+        tokens = full_text.split()
+        
+        # Keep last max_tokens
+        max_tokens = min(self.config.max_tokens, self.config.max_tokens_limit)
+        if len(tokens) > max_tokens:
+            tokens = tokens[-max_tokens:]
+        
+        return " ".join(tokens)
+    
+    def _update_sprt(self, escalation_prob: float) -> None:
+        """
+        Update SPRT log-likelihood ratio.
+        
+        LLR_n = LLR_{n-1} + log(P(x|H1) / P(x|H0))
+        
+        For continuous probability observations, we use a Bernoulli likelihood
+        where the observation is treated as a soft indicator:
+            LLR contribution = p * log(p1/p0) + (1-p) * log((1-p1)/(1-p0))
+        
+        This is equivalent to expected log-likelihood ratio under the
+        observed probability distribution.
+        """
+        eps = 1e-10
+        
+        # Bernoulli log-likelihood ratio with soft observation
+        # This correctly handles the full [0,1] range of escalation_prob
+        log_ratio_escalate = math.log((self.sprt_p1 + eps) / (self.sprt_p0 + eps))
+        log_ratio_no_escalate = math.log((1 - self.sprt_p1 + eps) / (1 - self.sprt_p0 + eps))
+        
+        # Expected LLR contribution = p * log(p1/p0) + (1-p) * log((1-p1)/(1-p0))
+        llr_contribution = (
+            escalation_prob * log_ratio_escalate +
+            (1 - escalation_prob) * log_ratio_no_escalate
+        )
+        
+        self._sprt_llr += llr_contribution
+    
+    def _check_escalation_sprt(self) -> Tuple[bool, Optional[str]]:
+        """
+        Check escalation using SPRT (Sequential Probability Ratio Test).
+        
+        Decision boundaries (Wald's approximation):
+        - Upper: A = log((1-beta)/alpha) → decide H1 (escalate)
+        - Lower: B = log(beta/(1-alpha)) → decide H0 (don't escalate)
+        
+        Returns:
+            (should_escalate, reason)
+        """
+        if self._sprt_llr >= self.sprt_upper_bound:
+            return True, f"sprt_upper_bound_crossed_llr_{self._sprt_llr:.3f}"
+        
+        # Note: we don't use lower bound to "commit" to non-escalation
+        # because safety requires we keep checking until conversation ends
+        return False, None
+    
+    def _check_escalation_k_consecutive(self, escalation_prob: float) -> Tuple[bool, Optional[str]]:
+        """
+        Check escalation using K-consecutive rule (original method).
+        
+        Rules:
+        1. Immediate if belief[ESCALATION] >= theta_hi
+        2. Escalate if belief[ESCALATION] >= theta_med for K consecutive steps
+        
+        Returns:
+            (should_escalate, reason)
+        """
+        # Rule 1: Immediate escalation
+        if escalation_prob >= self.config.theta_hi:
+            return True, f"immediate_high_prob_{escalation_prob:.3f}"
+        
+        # Rule 2: Consecutive steps above theta_med
+        if len(self._escalation_history) >= self.config.K:
+            recent = list(self._escalation_history)[-self.config.K:]
+            if all(p >= self.config.theta_med for p in recent):
+                return True, f"consecutive_{self.config.K}_steps_above_theta_med"
+        
+        return False, None
+    
+    def _check_escalation(self) -> Tuple[bool, Optional[str]]:
+        """
+        Check escalation decision rules based on decision_mode.
+        
+        Modes:
+        - K_CONSECUTIVE: Original threshold-based rules
+        - SPRT: Sequential Probability Ratio Test only
+        - HYBRID: SPRT with K-consecutive as fast-path fallback
+        
+        Returns:
+            (should_escalate, reason)
+        """
+        if self._escalated:
+            return True, "previously_escalated"
+        
+        escalation_prob = self.belief_updater.get_intent_prob("ESCALATION")
+        
+        # Track peak for near-miss detection
+        self._peak_escalation_prob = max(self._peak_escalation_prob, escalation_prob)
+        
+        # Update SPRT state
+        self._update_sprt(escalation_prob)
+        
+        if self.decision_mode == DecisionMode.K_CONSECUTIVE:
+            return self._check_escalation_k_consecutive(escalation_prob)
+        
+        elif self.decision_mode == DecisionMode.SPRT:
+            return self._check_escalation_sprt()
+        
+        elif self.decision_mode == DecisionMode.HYBRID:
+            # Fast-path: immediate high probability (K-consecutive rule 1)
+            if escalation_prob >= self.config.theta_hi:
+                return True, f"hybrid_immediate_high_prob_{escalation_prob:.3f}"
+            
+            # SPRT for statistical rigor
+            sprt_result, sprt_reason = self._check_escalation_sprt()
+            if sprt_result:
+                return True, f"hybrid_{sprt_reason}"
+            
+            # Fallback: K-consecutive as safety net
+            k_result, k_reason = self._check_escalation_k_consecutive(escalation_prob)
+            if k_result:
+                return True, f"hybrid_{k_reason}"
+            
+            return False, None
+        
+        # Default fallback
+        return self._check_escalation_k_consecutive(escalation_prob)
+    
+    def _check_commitment(self, top_intent: str, top_prob: float) -> Tuple[bool, Optional[str]]:
+        """
+        Check non-escalation intent commitment rules.
+        
+        Rules:
+        - Commit only if top_prob >= theta_lock AND stable top intent for K steps
+        
+        Returns:
+            (should_commit, committed_intent)
+        """
+        if self._committed:
+            return True, self._committed_intent
+        
+        # Don't commit to ESCALATION through this path
+        if top_intent == "ESCALATION":
+            return False, None
+        
+        # Check probability threshold
+        if top_prob < self.config.theta_lock:
+            return False, None
+        
+        # Check stability: same top intent for K steps
+        if len(self._top_intent_history) < self.config.K:
+            return False, None
+        
+        recent = list(self._top_intent_history)[-self.config.K:]
+        if all(intent == top_intent for intent in recent):
+            return True, top_intent
+        
+        return False, None
+    
+    def get_metrics(self) -> Dict[str, Any]:
+        """Get current metrics."""
+        return self.metrics.get_summary()
+    
+    def set_model_fn(self, model_fn: Callable[[str], Dict[str, float]]) -> None:
+        """Set or update the model inference function."""
+        self.model_fn = model_fn
+    
+    @property
+    def window_text(self) -> str:
+        """Current rolling window text."""
+        return self._window_text
+    
+    @property
+    def belief(self) -> Dict[str, float]:
+        """Current belief state."""
+        return self.belief_updater.get_belief_dict()
+    
+    @property
+    def is_committed(self) -> bool:
+        """Whether a final intent has been committed."""
+        return self._committed
+    
+    @property
+    def is_escalated(self) -> bool:
+        """Whether escalation has been triggered."""
+        return self._escalated