Good Clinical Documentation and the Telephone Triage Nurse


TriageLogic

By Heather Jarvis

When it comes to documenting triage calls, there’s always a fine balance between effective communications and liability risk. Nurses want to—and need to—effectively communicate information and directions to patients and those who may see their notes after the call. However, triage nurses must also cover themselves when it comes to liability.

So, what elements make good call documentation? Here are three tips to make sure your calls are well documented.

There’s always a fine balance between effective communications and liability risk. Click To Tweet

1. Make Your Communication Clear

Read your notes out loud and ask yourself, would this make sense to anyone else who reads it? Have I used the appropriate words? Does it have a definitive beginning and end?

2. Make Your Communication Concise

Think about what your narrative will look like to others. This applies not only to the next caregiver but six months or a year later when your instructions may face review. Are your communications direct and to the point?

3. Make Your Communication Credible

Use appropriate terminology, punctuation, and abbreviations. Make sure that others would view your documentation as written by someone who is knowledgeable. Always stick to the facts. Avoid jargon or slang. If a patient says she has a tummy ache, put that information in quotes so it’s known these were the patient’s words. Nurse triage documentation is not the place for personal views.

Conclusion

It’s important to remember that a nurse is judged by a reasonable standard: what a reasonable nurse would have done under the same or similar circumstances.

Every nurse wants to provide the best care, perfect care. But perfect care is not what the law requires. The law requires that a triage nurse provide reasonable care. Clear, concise, and credible documentation is always a best practice.

TriageLogic

Heather Jarvis is the communications and client engagement specialist at Triage Logic.