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R-IDEA

I - Interpretive Summary

Provides a concise summary statement that uses semantic vocabulary to highlight the most important elements from history, exam, and testing and to interpret and represent the patient's main problem (s). The presence or absence of the following features is assessed:

a) Key risk factors
b) Chief complaint
c) Illness time course; and
d) Use of semantic qualifiers

SCORING

  • 0 - No features present
  • 1 - 1 feature present
  • 2 - 2 features present
  • 3 - 3 features present
  • 4 - 4 features present

D - Differential Diagnosis

Offers more than one relevant diagnostic possibility, committing to what is most likely and considering what is less likely or unlikely yet important to consider for the main chief complaint. If the chief complaint is a diagnosis or syndrome (e.g. acute on chronic systolic heart failure) then differential to rate may be around the differential for that exacerbation (e.g. medication non-compliance vs arrythmia)

SCORING

  • 0 - No differential
  • 1 - Differential is implicitly stated, given as a diagnostic category (e.g, cardiac), OR implicitly prioritized
  • 2 - Differential is explicitly stated AND explicitly prioritized

E - Explanation of Lead Diagnosis

Explains the reasoning behind the lead diagnosis, including the epidemiology and key features and how these compare with the patient's presentation. If objective data points are not clearly linked to the lead diagnosis or alternative diagnosis, then only designate points to lead OR alternative diagnosis and NOT both.

SCORING

  • 0 - No explanation
  • 1 - 1 objective data point in explanation of the lead diagnosis
  • 2 - >= 2 objective data points in explanation of lead diagnosis

A - Alternative Diagnosis Explained

Explains the reasoning behind alternative diagnoses, including the epidemiology and key features and how these compare with the patient's presentation and alternative diagnosis. If objective data points are not clearly linked to the lead diagnosis or alternative diagnosis, then only designate points to lead OR alternative diagnosis and NOT both.

SCORING

  • 0 - No explanation for any alterative diagnosis
  • 1 - 1 objective data point in explanation of at least one alternative diagnosis
  • 2 - >= 2 objective data points in explanation of at least one alternative diagnosis