Score from the de-identified screenshots. Items 1–6 are each scored 1, 0.5 or 0.
1 · Chief complaint
Free-text narrative beyond the category button. Multiple buttons stacked (e.g. "Suicide Ideation / Depressed / Hearing Voices") are NOT narrative — that is still 0.
1Describes the presenting problem
0.5Brief or vague free text
0Category button(s) only — no free text
2 · Why today
Trigger, context AND duration of why they came today.
1All three present
0.5Some present
0None documented
3 · Background history
Psychiatric history established, including explicit "nil known".
1Established / "nil known" stated
0.5Partial — some elements missing
0Not addressed / blank
4 · History source
Informant noted AND collateral account written into the record (paraphrased or verbatim).
1Informant + account written in
0.5Collateral involved but account not written in (e.g. "refer to memo")
0Source not addressed
5 · Behavioural observation (MSE + BARS)
MSE consistent with the complaint AND BARS consistent with MSE.
1Consistent throughout
0.5"Abnormal/Others" with no comment, or minor BARS–MSE mismatch
0Floor to 0 when the patient is high-risk AND the MSE is absent, all-normal, or contradicted by BARS. High-risk = C-SSRS Red · OR homicidal (aggression: thoughts + intent/plan) · OR a suicide/self-harm/homicidal complaint where C-SSRS was not done. (A bland "all-normal" MSE on any of these scores 0, regardless of how calm the patient looked.)
6 · C-SSRS
Complete per branching logic, with risk level stated. (Q2 = No → only Q1/Q2/Q6 expected — do not penalise a short C-SSRS.)
1Completed and correctly branched; risk level stated
0.5Not obtained, but refusal / "unable to assess" documented anywhere in the record
0Blank — not done, no comment
Note: a documented refusal still means no risk data was obtained. "C-SSRS not done" is different from "C-SSRS done, all-negative (No Risk)" — don't record a not-done screen as a colour.
Item 7 · Acuity concordance
Matrix-verified (suicide-risk cases): pick BARS + C-SSRS — the tool checks the assigned PAC against the WI-ESD-005/F02 matrix (shown on the scoring screen).
Clinical-judgement (other presentations): you judge whether the PAC fits the severity.
Item 8 · Redirection
Did the triager document their reasoning about whether the patient suited Emergency Services or could be redirected elsewhere (e.g. polyclinic, GP, scheduled appointment)? This scores the documentation, not whether redirection actually happened — a patient who clearly needed the ED still scores 1 if the reason ES was appropriate is written down. Office hours 08:00–17:00 Mon–Fri only.
1Considered, with a reason written (e.g. "advised GP but patient insists on ED review", or "appropriate for ES — acute risk")
0.5Mentioned but no reason given (e.g. just "not redirected")