Table 1 Triage note groups and specific documentation criteria used ( + is CDS generated; *is CDS prompted)
Triage documentation category | Triage note documentation elements (present/absent) |
|---|---|
Encounter characteristics | +1. Date/Time of encounter |
*2. Telephone number from where calling (in case of disconnecting) | |
*3. Telephone number of where the patient can be reached (has to be in note) | |
+4. Name of Nurse | |
Patient characteristics | *1. Patient name (full first and last) |
+2. Date of birth (month, day and year) | |
+3. Gender | |
4. Past medical history (any documentation of past or ongoing diseases or conditions, this would be chronic conditions such as diabetes, hypertension, sleep apnea) | |
5. Allergies (only if in note) | |
6. Current medications (any mention of ongoing medications or those already taken for the specific symptom) | |
Contact characteristics | *1. Caller is clearly identifiable (this may be implied) |
*2. Contact person’s name (caller’s first and last name if not patient) | |
*3. Relationship to patient if patient is not caller (must have specific relationship documented) | |
Reason for call | 1. Reason for the encounter |
2. Chief symptoms, complaint, or information desired | |
3. Presence or absence of symptoms | |
*4. Whether the patient has called before with a similar complaint or information request (recent nurse line call or provider contact for the same complaint within the past 1 week) | |
Nursing actions | *1. Assessment of symptoms and situation (main symptom stated explicitly) |
+2. Specific decision support tool used (clear documentation of any ancillary sources of information used to make decision- including provider input) | |
+3. Plan of action (clear documentation of disposition, must contain time frame) | |
*4. Intervention or information given (any care points, home cares, treatments or protocols documented in note; this doesn’t include advice for what to do with change in symptoms) | |
5. Referrals to services, providers (other than the specific disposition- examples would be home health care, specialty appointment, infusion therapy center, etc.) | |
6. Coordination of care arranged (conversation/communication with provider, documentation of arrangement for further care such as transferring to appointment coordinator or calling ED- this must be documented, not implied) | |
Post-triage disposition actions | *1. Patient understanding (documentation that patient or caller understands plan of care) |
*2. Documentation of patient agree or disagree (refusal or agreement with care) | |
*3. Nurse's rebuttal documented | |
*4. Patient or caller response to rebuttal documented |