Learn · Guide 02
Documenting risk
A risk score by itself protects no one. The value is the sentence after it: what the score was, and what you did because of it.
01Use a named tool, and cite it
When a rule fits, use it by name: HEART, Wells, PERC, Ottawa. It shows your call was anchored to something other than the hour of the night. Stay inside the population the rule was built for.
02A number isn’t a decision
▼ floating
“HEART score 3.”
▲ anchored
“HEART score 3 (low risk). With a non-ischemic ECG and negative troponin, outpatient follow-up is appropriate.”
03Say the residual risk
Low risk isn’t no risk. “Low-risk for ACS by HEART, small residual risk discussed with the patient” is both more honest and harder to attack than “no evidence of ACS.”1
04Document the shared decision
▼ unilateral
“Discharged. Follow up with cardiology.”
▲ shared
“Options of observation vs. outpatient workup discussed. Patient understands the low residual risk and prefers outpatient follow-up within 72h.”
Build it
The Workup wires a cited risk tool (HEART, Wells, PERC) into a paste-in block.
Educational only. Synthetic examples, including any risk figures. Not medical advice.
Reference
- Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008;16(6):191–196.