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Table 1 Triage note groups and specific documentation criteria used ( + is CDS generated; *is CDS prompted)

From: Clinical decision support improves quality of telephone triage documentation - an analysis of triage documentation before and after computerized clinical decision support

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
  1. +CDS generated; *CDS prompted.