Scribe BC - MULTIPLE CLINICAL RISK SCORES TEMPLATE

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."