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.
1Describes the presenting problem
0.5Brief or vague free text
0Category button 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
0MSE absent · OR MSE normal but complaint high-risk (active SI / homicidal ideation) · OR BARS contradicts MSE in a high-risk case
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.)
1Complete; risk level stated
0.5Partly completed or risk level missing
0Not completed
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")