IMH ES Triage Audit

How to score each record

Score from the de-identified screenshots. Items 1–5 are each scored 1, 0.5 or 0. Background history has been dropped this round — if you scored the baseline, note MSE is now Item 4 and C-SSRS is Item 5.

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 · 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

4 · 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

0Red-flag rule — score 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.)

5 · 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 6 · 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 7 · 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")

0Nothing documented about redirection

N/AArrived outside office hours (set automatically)

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