Scribe BC - MULTIPLE CLINICAL RISK SCORES TEMPLATE
HEIDI UNIVERSAL CLINICAL SCORING & RISK TOOL TEMPLATE
(For all clinical scoring algorithms, display only if ≥2 required fields are documented. Omit unused lines, placeholders, and irrelevant criteria. Never fabricate values. If a field is not documented, display "Not documented".)
(Preferred clinical scoring algorithms are CENTOR, WELLS, PERC, CHADS2-VASc, HAS-BLED, NIHSS, GCS, SIRS, HEART, TIMI, ABCD2, OTTAWA ANKLE RULE, PHQ-9, GAD-7, PRAM)
GLOBAL RULE:
For every clinical scoring algorithm:
[IF two or more required scoring fields are documented THEN]
(Display the score name and context)
(Display criteria and their values; if a criterion is not recorded, show "Not documented")
(Display only the total score and risk category/interpretation)
[ENDIF]
------------------------------------------------------------
[IF two or more required CENTOR fields are noted THEN]
CENTOR SCORE FOR STREP PHARYNGITIS
(Score each criterion as per standard Centor scoring; display only final score and risk level)
Criteria:
- Tonsillar exudates: Yes
- Tender anterior cervical lymph nodes: Yes
- Absence of cough: Yes
TOTAL CENTOR SCORE: 3
RISK ASSESSMENT: Moderate
[ENDIF]
------------------------------------------------------------
[IF two or more required Wells fields are noted THEN]
WELLS SCORE FOR DVT / PE
Criteria:
- Active cancer: Yes
- Alternative diagnosis less likely than PE: Yes
- Tachycardia: Yes
TOTAL WELLS SCORE: 6
RISK ASSESSMENT: High
[ENDIF]
------------------------------------------------------------
[IF two or more required PERC fields are noted THEN]
PERC RULE FOR PE
Criteria:
- Age < 50: Yes
- Heart rate < 100 bpm: Yes
- Oxygen saturation > 95%: Yes
TOTAL PERC POSITIVE: 0
INTERPRETATION: PERC negative
[ENDIF]
------------------------------------------------------------
[IF two or more required HAS-BLED fields are noted THEN]
HAS-BLED SCORE FOR BLEEDING RISK
Criteria:
- Hypertension: Yes
- Age >65: Yes
- Previous stroke: Yes
TOTAL HAS-BLED SCORE: 4
RISK CATEGORY: High
[ENDIF]
------------------------------------------------------------
[IF two or more required CHADS-2 fields are noted THEN]
CHADS-2 / CHA₂DS₂-VASc SCORE FOR STROKE RISK
Criteria:
- Congestive heart failure: Yes
- Hypertension: Yes
- Age >75: Yes
TOTAL CHADS-2 SCORE: 4
TOTAL CHA₂DS₂-VASc SCORE: 6
RISK CATEGORY: High
[ENDIF]
------------------------------------------------------------
[IF two or more required NIHSS fields are noted THEN]
NIH STROKE SCALE (NIHSS)
TOTAL NIHSS SCORE: 12
Severity Tier:
- 0: No stroke symptoms
- 1–4: Minor stroke
- 5–15: Moderate stroke
- 16–20: Moderate to severe stroke
- 21–42: Severe stroke
[ENDIF]
------------------------------------------------------------
[IF two or more required Glasgow Coma Scale fields are noted THEN]
GLASGOW COMA SCALE (GCS)
Eye opening: 4
Verbal response: 5
Motor response: 6
TOTAL GCS SCORE: 15
INTERPRETATION: Mild brain injury
[ENDIF]
------------------------------------------------------------
[IF two or more required CURB-65 fields are noted THEN]
CURB-65 SCORE FOR PNEUMONIA SEVERITY
Criteria:
- Confusion: 1
- Urea >7 mmol/L: 1
- RR ≥30: 1
- BP (SBP <90 or DBP ≤60): 0
- Age ≥65: 1
TOTAL CURB-65 SCORE: 4
RISK CATEGORY: High
[ENDIF]
------------------------------------------------------------
[IF two or more required SOFA fields are noted THEN]
SOFA SCORE FOR ORGAN FAILURE
TOTAL SOFA SCORE: 8
RISK ASSESSMENT: High
[ENDIF]
------------------------------------------------------------
[IF two or more required qSOFA fields are noted THEN]
QUICK SOFA (qSOFA)
Criteria:
- RR ≥22: 1
- Altered mentation: 1
- SBP ≤100: 1
TOTAL qSOFA SCORE: 3
INTERPRETATION: High risk of poor outcome
[ENDIF]
------------------------------------------------------------
[IF two or more required SIRS fields are noted THEN]
SIRS CRITERIA FOR SEPSIS RISK
Criteria:
- Temp abnormal: 1
- HR >90: 1
- RR >20 or PaCO₂ <32: 1
- WBC abnormal: 1
TOTAL SIRS SCORE: 4
INTERPRETATION: SIRS positive
[ENDIF]
------------------------------------------------------------
[IF two or more required HEART fields are noted THEN]
HEART SCORE FOR CHEST PAIN
Criteria:
- History: 2
- ECG: 1
- Age: 1
- Risk factors: 1
- Troponin: 1
TOTAL HEART SCORE: 6
RISK CATEGORY: High
[ENDIF]
------------------------------------------------------------
[IF two or more required TIMI fields are noted THEN]
TIMI SCORE FOR ACS RISK
TOTAL TIMI SCORE: 5
RISK CATEGORY: Intermediate
[ENDIF]
------------------------------------------------------------
[IF two or more required ABCD² fields are noted THEN]
ABCD² SCORE FOR TIA RISK
TOTAL ABCD² SCORE: 6
RISK CATEGORY: High
[ENDIF]
------------------------------------------------------------
[IF two or more required Ottawa Ankle Rule fields are noted THEN]
OTTAWA ANKLE RULES
Criteria:
- Inability to bear weight: Yes
- Tenderness to palpation of the malleoli: Yes
INTERPRETATION: X-ray indicated
[ENDIF]
------------------------------------------------------------
[IF two or more required PHQ-9 fields are noted THEN]
PHQ-9 DEPRESSION SCREEN
TOTAL PHQ-9 SCORE: 18
SEVERITY: Moderately severe
[ENDIF]
------------------------------------------------------------
[IF two or more required GAD-7 fields are noted THEN]
GAD-7 ANXIETY SCREEN
TOTAL GAD-7 SCORE: 14
SEVERITY: Severe
[ENDIF]
------------------------------------------------------------
[IF two or more required Pediatric Asthma Score fields are noted THEN]
PEDIATRIC ASTHMA SCORE
TOTAL SCORE: 7
SEVERITY: Moderate
[ENDIF]
"This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian."
Scribe BC - MULTIPLE CLINICAL RISK SCORES TEMPLATE
HEIDI UNIVERSAL CLINICAL SCORING & RISK TOOL TEMPLATE
(For all clinical scoring algorithms, display only if ≥2 required fields are documented. Omit unused lines, placeholders, and irrelevant criteria. Never fabricate values. If a field is not documented, display "Not documented".)
(Preferred clinical scoring algorithms are CENTOR, WELLS, PERC, CHADS2-VASc, HAS-BLED, NIHSS, GCS, SIRS, HEART, TIMI, ABCD2, OTTAWA ANKLE RULE, PHQ-9, GAD-7, PRAM)
GLOBAL RULE:
For every clinical scoring algorithm:
[IF two or more required scoring fields are documented THEN]
(Display the score name and context)
(Display criteria and their values; if a criterion is not recorded, show "Not documented")
(Display only the total score and risk category/interpretation)
[ENDIF]
------------------------------------------------------------
[IF two or more required CENTOR fields are noted THEN]
CENTOR SCORE FOR STREP PHARYNGITIS
(Score each criterion as per standard Centor scoring; display only final score and risk level)
Criteria:
- [Criterion 1]: [value] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Criterion 2]: [value] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
TOTAL CENTOR SCORE: [value] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
RISK ASSESSMENT: [Low / Moderate / High] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[ENDIF]
------------------------------------------------------------
[IF two or more required Wells fields are noted THEN]
WELLS SCORE FOR DVT / PE
Criteria:
- [Criterion 1]: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Criterion 2]: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
TOTAL WELLS SCORE: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
RISK ASSESSMENT: [Low / Moderate / High or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[ENDIF]
------------------------------------------------------------
[IF two or more required PERC fields are noted THEN]
PERC RULE FOR PE
Criteria:
- [Criterion 1]: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Criterion 2]: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
TOTAL PERC POSITIVE: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
INTERPRETATION: [PERC negative / PERC positive or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[ENDIF]
------------------------------------------------------------
[IF two or more required HAS-BLED fields are noted THEN]
HAS-BLED SCORE FOR BLEEDING RISK
Criteria:
- [Criterion 1]: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Criterion 2]: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
TOTAL HAS-BLED SCORE: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
RISK CATEGORY: [Low / Moderate / High or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[ENDIF]
------------------------------------------------------------
[IF two or more required CHADS-2 fields are noted THEN]
CHADS-2 / CHA₂DS₂-VASc SCORE FOR STROKE RISK
Criteria:
- [Criterion 1]: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Criterion 2]: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
TOTAL CHADS-2 SCORE: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
TOTAL CHA₂DS₂-VASc SCORE: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
RISK CATEGORY: [Low / Moderate / High or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[ENDIF]
------------------------------------------------------------
[IF two or more required NIHSS fields are noted THEN]
NIH STROKE SCALE (NIHSS)
TOTAL NIHSS SCORE: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Severity Tier:
- 0: No stroke symptoms
- 1–4: Minor stroke
- 5–15: Moderate stroke
- 16–20: Moderate to severe stroke
- 21–42: Severe stroke
[ENDIF]
------------------------------------------------------------
[IF two or more required Glasgow Coma Scale fields are noted THEN]
GLASGOW COMA SCALE (GCS)
Eye opening: [1–4 or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Verbal response: [1–5 or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Motor response: [1–6 or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
TOTAL GCS SCORE: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
INTERPRETATION: [Mild / Moderate / Severe brain injury or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[ENDIF]
------------------------------------------------------------
[IF two or more required CURB-65 fields are noted THEN]
CURB-65 SCORE FOR PNEUMONIA SEVERITY
Criteria:
- Confusion: [0/1 or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Urea >7 mmol/L: [0/1 or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- RR ≥30: [0/1 or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- BP (SBP <90 or DBP ≤60): [0/1 or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Age ≥65: [0/1 or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
TOTAL CURB-65 SCORE: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
RISK CATEGORY: [Low / Moderate / High or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[ENDIF]
------------------------------------------------------------
[IF two or more required SOFA fields are noted THEN]
SOFA SCORE FOR ORGAN FAILURE
TOTAL SOFA SCORE: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
RISK ASSESSMENT: [Low / Moderate / High or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[ENDIF]
------------------------------------------------------------
[IF two or more required qSOFA fields are noted THEN]
QUICK SOFA (qSOFA)
Criteria:
- RR ≥22: [0/1 or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Altered mentation: [0/1 or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- SBP ≤100: [0/1 or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
TOTAL qSOFA SCORE: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
INTERPRETATION: [Low / High risk of poor outcome or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[ENDIF]
------------------------------------------------------------
[IF two or more required SIRS fields are noted THEN]
SIRS CRITERIA FOR SEPSIS RISK
Criteria:
- Temp abnormal: [0/1 or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- HR >90: [0/1 or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- RR >20 or PaCO₂ <32: [0/1 or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- WBC abnormal: [0/1 or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
TOTAL SIRS SCORE: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
INTERPRETATION: [SIRS positive / negative or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[ENDIF]
------------------------------------------------------------
[IF two or more required HEART fields are noted THEN]
HEART SCORE FOR CHEST PAIN
Criteria:
- History: [0/1/2 or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- ECG: [0/1/2 or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Age: [0/1/2 or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Risk factors: [0/1/2 or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Troponin: [0/1/2 or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
TOTAL HEART SCORE: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
RISK CATEGORY: [Low / Moderate / High or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[ENDIF]
------------------------------------------------------------
[IF two or more required TIMI fields are noted THEN]
TIMI SCORE FOR ACS RISK
TOTAL TIMI SCORE: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
RISK CATEGORY: [Low / Intermediate / High or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[ENDIF]
------------------------------------------------------------
[IF two or more required ABCD² fields are noted THEN]
ABCD² SCORE FOR TIA RISK
TOTAL ABCD² SCORE: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
RISK CATEGORY: [Low / Moderate / High or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[ENDIF]
------------------------------------------------------------
[IF two or more required Ottawa Ankle Rule fields are noted THEN]
OTTAWA ANKLE RULES
Criteria:
- [Criterion 1]: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Criterion 2]: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
INTERPRETATION: [X-ray indicated / Not indicated or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[ENDIF]
------------------------------------------------------------
[IF two or more required PHQ-9 fields are noted THEN]
PHQ-9 DEPRESSION SCREEN
TOTAL PHQ-9 SCORE: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
SEVERITY: [Minimal / Mild / Moderate / Moderately severe / Severe or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[ENDIF]
------------------------------------------------------------
[IF two or more required GAD-7 fields are noted THEN]
GAD-7 ANXIETY SCREEN
TOTAL GAD-7 SCORE: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
SEVERITY: [Minimal / Mild / Moderate / Severe or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[ENDIF]
------------------------------------------------------------
[IF two or more required Pediatric Asthma Score fields are noted THEN]
PEDIATRIC ASTHMA SCORE
TOTAL SCORE: [value or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
SEVERITY: [Mild / Moderate / Severe or Not documented] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[ENDIF]
"This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian."
(Never come up with your own patient details, assessment, plan, interventions, evaluation, or plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs, or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
