Triage Documentation: Setting a Best Practice

By Barton D. Schmitt, M.D., FAAP and David A. Thompson, M.D., FACEP

[Quality monitoring programs for triage include many components, one of which is documentation. When the practice of triage nurses is at the extremes, from sparse documentation to a novella of the caller’s entire health history, it is easy to identify areas for improvement. But that still begs the questions, “How much is enough?” and “What items should be present in the final call document?” The call center manager still needs to describe the best practice and coach his/her staff to that benchmark.

These questions have been posed to Drs. Barton Schmitt and David Thompson, authors of the leading telephone triage protocols. Both have actively worked with staff as Medical Directors for their own triage call centers. The following is an excerpt from their combined thinking.]

Triage is the decision process of sorting patients to the level of care that best meets their medical needs. This decision process must take into consideration the seriousness (medical acuity) of the patient’s medical complaint, the types of resources required to provide effective care, the patient’s expectations, and several other factors. Effective and concise documentation should support the decision process.   Here are some documentation examples for chronic illness, current medications, allergies, and social history.

Chronic Illness – The Active Problem List: Documentation of pertinent chronic illness is indicated in most calls. Documentation should not be a comprehensive listing of every medical and surgical problem that the patient has ever had. Instead, it should reflect current ongoing medical problems (the active problem list).

The higher the acuity of the disposition, the less documentation of chronic illness will be needed. A patient who obviously requires an EMS 911 or GO TO ED NOW disposition needs a very abbreviated documentation of chronic illness.

The Schmitt-Thompson protocols contain Initial Assessment Questions that prompt the triage nurse to inquire about key chronic illnesses for certain complaints. For example, the pediatric Hives protocol contains the following Initial Assessment Question:

RECURRENT PROBLEM: “Has your child had hives before?” If so, ask: “When was the last time?” and “What happened that time?”

The protocols contain Triage Questions that prompt the triage nurse to inquire about key chronic illnesses for certain complaints and then the protocols recommend a disposition. For example, the adult Puncture Wound protocol suggests a SEE PCP WITHIN 3 DAYS if the patient is: [1] Diabetic AND [2] puncture wound of foot

Another example from the pediatric Headache protocol is: [1] High-risk child (e.g. bleeding disorder. V-P shunt, CNS disease) AND [2] new headache

When documentation of chronic illness is indicated, the recorded information can often be very brief. For example, the triage nurse could document past medical history (PMH) and past surgical history (PSH) in the following manner: PMH – diabetes; PSH – coronary bypass surgery

Current Medications: It is reasonable and appropriate to document medications to the extent that they are pertinent to the presenting complaint and affect the disposition. Sometimes inquiring about current medications reveals a Chronic Illness that the caller had forgotten or denied. Documenting every medication that a patient takes on every call is time-consuming and not necessary.

The higher the acuity of the disposition, the less that the medications will need to be documented. A patient who requires an EMS 911 disposition rarely needs any documentation of medications. Such rare circumstances would include a life-threatening reaction to the medication, for example, anaphylaxis or profound hypoglycemia. And in such a circumstance, documentation should not delay completion of the call. A patient that requires a GO TO ED NOW disposition uncommonly needs to have medications documented.

Schmitt-Thompson’s Initial Assessment Questions prompt the nurse to inquire about key medications for certain complaints. For example, the pediatric Asthma protocol contains the following Initial Assessment Question:

MEDICATIONS (MDI or nebs): “What is your child’s asthma medicine?” and “What treatments have you given so far?” The neb or inhaler treatments listed in the triage questions refers to Albuterol or other rescue, quick-relief, beta-agonist medicines (not steroids, cromolyn, or other anti-inflammatory medicines).

The Triage Questions prompt the nurse to inquire about key medications for certain complaints, and then suggests a disposition, For example, the adult Trauma-Head protocol recommends a GO TO ED NOW (or PCP triage) disposition if the patient is:

Taking coumadin or known bleeding disorder (e.g. thrombocytopenia)

When medication documentation is appropriate, the recorded information can often be very brief:

MEDS – amoxicillin, started yesterday

Documenting the exact dosage of a medication or dosing interval is not necessary, unless either:

  1. The patient has a specific medication question, or
  2. An adverse drug reaction (dose-related side effect or overdose) is suspected by the triage nurse or caller, or
  3. The triage nurse is calling in a prescription (by physician order and per protocol) for a medication (e.g. antibiotic eye drops for purulent conjunctivitis, nystatin for oral thrush).

Medication Allergies: Medication allergies are only rarely pertinent to the presenting complaint and the triage decision-making process. Medication allergies should be documented in the following two circumstances:

  1. Presenting complaint of rash
  2. Triage nurse is calling in a new prescription (by physician order and per protocol), calling in a refill (per call center policy), or recommending an Over-the-Counter medication (per call center policy and protocol).

Social History: There are a number of social factors that may influence triage decision-making. Social history only needs to be documented if it affects the triage disposition. The triage nurse can use the acronym to remember important social factors.

The Schmitt-Thompson Initial Assessment Questions prompt the triage nurse to inquire about key chronic illnesses for certain complaints. For example, the adult Anxiety and Panic Attack protocol contains the following Initial Assessment Question:

SUBSTANCE ABUSE: “Do you use any illegal drugs or alcohol?”

The Triage Questions prompt the triage nurse to inquire about key chronic issues for certain complaints, and then the protocols recommend a disposition. For example, the pediatric Bruises protocol suggests a GO TO ED NOW (or PCP triage) if

Suspicious history for the injury (R/O: child abuse)

When social history documentation is appropriate, the recorded information can often be very brief:

SH – lives alone, has car

Copyright 2004. David Thompson MD, Barton Schmitt MD. For a copy of the full document, email Sue Altman at sue@selfcare.info.

[From the October/November 2005 issue of AnswerStat magazine]