By Ravi K. Raheja, MD
By the very nature of their profession, telephone triage nurses can’t physically see their patient callers. This begs the question, what kind of liability do they face when they provide dispositions for care?
That’s why we were excited to sit down with D.D. Fritch, MSN, MHA, RN, a tenured clinical leader in this area of healthcare, who was happy to shed some light on the legal perspective and why it’s crucial for nurses to have the proper documentation.
Question: Tell us a little about your background. What’s your experience with nurse liability as it pertains to telephone/telehealth triage? How did you get involved in nurse triage?
Answer: I am a pediatric nurse of 33 years, working as a nurse and nurse leader at Children’s Healthcare of Atlanta for 31 years. During my tenure at Children’s, I was the director of the contact center for nine years, which was responsible for their Nurse Advice Line. Since 2018, I have been working as a healthcare consultant, assisting clients with clinical call management, call center operations, and practice administration.
As far as my experience with nurse liability, whether a nurse is practicing in person or virtually, the liability is the same. With that being said, nurse triage has many components of liability that need to be considered.
Q: What information should triage nurses make sure is documented in every clinical note?
A: Documentation is vital. Document the patient’s history, findings, dispositions, what the caller describes verbatim, and the nursing education that is provided. Documentation as a nurse working on the phone is not very different than in person, but there is a skillset to communicating with the patient or caregiver to ensure that documentation is complete and accurate.
Q: What factors are important for the credibility of a clinical note?
A: Credibility comes from documenting the facts, and when you are a triage nurse it is vital for you to record the initial concern as the caller describes. “Reading into” what the caller is saying is very different than completing an assessment and documenting the findings of that assessment.
Q: What happens if a patient has a bad outcome following a triage call that relates to the symptoms they were calling about?
A: This is a broad question. Organizationally, the chart should be reviewed to see if there were any opportunities where the nurse should have acted differently or made a different decision. If the triage company is acting on behalf of a provider, the provider should be notified and the situation should be discussed.
If there is an untoward event due to negligence of the triage nurse, then the nurse and the organization that they work for or represent could be liable.
Q: What would need to be proven for a lawsuit to move forward against a triage nurse or their organization or practice?
A: Each state has licensing requirements, and the nurse always needs to practice within scope and according to their license. Practicing out of scope would be a significant concern in a lawsuit.
Q: Do juries tend to look upon nurses in a particular light? For example, do they tend to trust their judgment?
A: The nurse has a license to uphold and an ethical duty to serve, just as any other credentialed witness would.
Q: When is the duty to a patient caller established?
A: Upon initial connection with the nurse.
Q: If a specific nurse triage line is set up solely for patients of a particular healthcare provider, and someone calls in who is not currently a patient, what is the legal responsibility of the nurse who answers that call? How should they respond?
A: This depends on how the call is handled on the front end. Many times the nurse is not the first one to speak to the caller. This information would need to be a part of the initial information gathering prior to any clinical information being captured.
Q: When using Schmitt-Thompson protocols to evaluate a patient caller’s symptoms, do triage nurses need to document all negative responses leading up to the first positive response?
A: How the nurse documents is up to the provider or organization. There is an option to document all negatives or only the positives. Either way, there needs to be an organizational policy and then training for staff to ensure that there is consistency.
Q: How should a triage nurse handle documentation they may have missed adding to a patient’s chart during a call? Are there things they shouldn’t do if they need to update a chart?
A: Document any late entries as an addendum, ensuring that the time and date of the entry as well as the interaction are captured.
Q: Is there any additional information you’d like to add regarding the legal responsibilities and requirements for telephone or telehealth nurse triage?
A: Legal considerations as a triage nurse are something that should be a topic of education and continued competency on an ongoing basis. Quality audits should also be a part of the operating procedures of the nursing leadership team.
Registered nurses are licensed in the state in which they practice (where the patient is located). The nurse should be familiar with clinical protocols and nurse triage details related to their Nurse Practice Act in each state in which they practice. Most states require that nurse triage be performed by a registered nurse. Educate yourself on what your state requires.
In addition, the book The Art and Science of Telephone Triage: How to Practice Nursing Over the Phone, written by Carol Rutenberg and M. Elizabeth Greenberg, is a good resource. There is a chapter on risk management and common pitfalls.
D.D. Fritch is passionate about enhancing care for children and patients through technology. As a nursing leader, D.D. spent most of her 32-year career at Children’s Healthcare of Atlanta, improving its contact center, supporting its telemedicine program, and optimizing its Pediatric Nurse Advice Line. Connect with her at dd@connected2consulting.org.
Ravi K. Raheja, MD is the CTO and medical director of the TriageLogic Group. Founded in 2007, TriageLogic is a URAC accredited, physician-led provider of high-quality telehealth services, remote patient monitoring, nurse triage, triage education, and software for telephone medicine. Their comprehensive solutions include integrated mobile access and two-way video capability. The TriageLogic group serves over 9,000 physicians and covers over twenty-five million lives nationwide.