Scales and exams

Where to start

During a session recording, click Scales or press M.

On an encounter note:

Click Edit.
Click Assessments. The tooltip reads Assessments, Scales, and Exams.

You can also type /note and select Note Component.

On Write a note:

Open the Context tab.
Click Assessments.

The Note tab has no Assessments control.

Find a measure

The dialog title is Add a scale or exam. The description is Choose a measure to complete for this session. The field is Find a scale or exam.

The closed control reads Search scales and exams.... Search by name, abbreviation, or topic. The field shows Search by name, abbreviation, or topic.... The results appear under Scales and Exams. The list includes measures that you saved before. If nothing matches, the list says No scales or exams match your search.

Scales

Columbia–Suicide Severity Rating Scale (C-SSRS) — Recent Screener
Ask Suicide-Screening Questions (ASQ)
Edinburgh Postnatal Depression Scale (EPDS)
Geriatric Depression Scale — 15 item (GDS-15)
Center for Epidemiologic Studies Depression Scale (CES-D20)
Hamilton Depression Rating Scale — 17 item (HAM-D17)
Altman Self-Rating Mania Scale (ASRM)
Patient Health Questionnaire — Panic Disorder module (PHQ-PD)
Hamilton Anxiety Rating Scale (HAM-A)
Obsessive-Compulsive Inventory — Revised (OCI-R)
Depression Anxiety Stress Scales — 21 item (DASS-21)
Kessler Psychological Distress Scale — 10 item (K10)
Self-Regulation Questionnaire — 63 item (SRQ63)
Primary Care PTSD Screen for DSM-5 (PC-PTSD-5)
International Trauma Questionnaire (ITQ)
Dissociative Symptoms Scale — Brief (DSS-B)
International Prolonged Grief Disorder Scale (IPGDS)
Mental Health Continuum — Short Form (MHC-SF)
Swanson, Nolan and Pelham Rating Scale IV, 26-item (SNAP-IV)
Screen for Child Anxiety Related Emotional Disorders (SCARED)
Pediatric Symptom Checklist, 17-item (PSC-17)
Affective Reactivity Index (ARI), six-month version
Child and Adolescent Trauma Screen 2 (CATS-2)
Behavior and Feelings Survey (BFS)
Ritvo Autism and Asperger Diagnostic Scale, 14-item Screen (RAADS-14)
Drug Use Disorders Identification Test (DUDIT)
Alcohol Use Disorders Identification Test (AUDIT)
Tobacco, Alcohol, Prescription Medication and Other Substance Use (TAPS)
Fagerstrom Test for Nicotine Dependence (FTND)
Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar)
Brief Addiction Monitor, Continuous (BAM-R)
Obsessive-Compulsive Inventory, Child Version, 5-item (OCI-CV-5)
Brief Screener for Tobacco, Alcohol and Other Drugs (BSTAD)
NIAAA Youth Alcohol Screen
Center for Epidemiological Studies Depression Scale for Children (CES-DC)
Bergen Insomnia Scale (BIS)
NoSAS Sleep Apnea Score
SCOFF Eating Disorder Screen
Eating Disorder Diagnostic Scale (EDDS-5)
Questionnaire on Eating and Weight Patterns (QEWP-5)
Satisfaction With Life Scale (SWLS)
Brief Inventory of Psychosocial Functioning (B-IPF)

Exams

Sleep Diary Assessment
Saint Louis University Mental Status (SLUMS)
4AT Delirium and Cognitive Screen
Bush–Francis Catatonia Rating Scale (BFCRS)
Barnes Akathisia Rating Scale (BARS)
Simpson–Angus Scale (SAS)
Brief Psychiatric Rating Scale (BPRS-18)
Clinical Global Impression (CGI-S / CGI-I)

Enter answers

The title changes to the instrument name. If the instrument has items, the description reads Enter any answers you have, then use the note, transcript, and attachments to fill supported responses.

Answer the items you can. Select a pill or enter a Score or Value. You can also type in Enter a response, or use context to fill it.

If the measure has a source page, click Administration and scoring guide to open it.

You can add Notes and attachments. The Notes field says Optionally add notes and context for the AI. Documents (optional) accepts up to five PDF or image files. Each file can be 10MB or less. The drop zone says Drop files here or click to browse.

Generate

Click Generate.

With nothing answered, the caption is Fill from context.
With some items answered, the caption counts them: 3 of 9 answered. Generation uses context for the remaining items.
With every item answered, the caption is All items answered. Generation keeps your exact values and computes scores.
With no item list, the caption is Uses the note, transcript, and attachments to generate the assessment.

On a narrow screen, the caption does not appear. The Generate button stays visible. During generation, the button reads Generating....

Your answers stay in place, including zero. Generate fills an unanswered item if the context supports the item, respondent, and time frame. The context includes the note, transcript, notes, and attachments. A normal finding fills its item. If the context does not support an item, it stays blank and shows as -. A recorded zero stays 0.

On the recorder, Generate uses the current transcript and context notes. On a note, it uses the current note text.

The Clinical observations use the settings for Verbosity, Voice style, and Global Instructions. Item values and scores use the answers.

You can edit the preview. Its label is Assessment preview. The description reads Review the generated measure. The content is editable before inserting.

If generation fails, the dialog says Failed to load content. Please try again.

Insert

Click Insert. During the save, the button reads Inserting.... The message shows Measure added and The measure has been added to the document.

The note block shows the instrument name, an Assessment line, the score summary, and a table of Recorded item and Value. If the record supports them, Clinical observations appear. The note editor marks the block Component. The recorder also stores the text as a context block with a time stamp. The block starts with [Scale/Exam: ] and the instrument name.

If the encounter has measures, the sidebar lists them under Scales & Exams. An empty sidebar says No scales or exams added yet. The Scales & Exams section of the patient chart says Assessment scales and clinical exams from sessions. Use Search scales & exams to search the chart. An empty chart says No scales or exams yet.