SCOPE: Anytime Pediatrics, Triage Nurse, Registered Nurse
POLICY: Documentation of the telephonic triage encounter provides a written summary of the interaction. Documentation serves as proof of encounter, collaboration, and application of nursing process as it relates to presented subjective and objective data collected during interaction.
PROCEDURES:
- Documentation should be entered into the Anytime Pediatrics Platform for each patient call.
- Documentation should be timely
- The following information will be included with each triage:
- Patient Demographics to include first and last name, DOB, caller’s name and relationship to the patient, call back number and clinician
- Patient complaint
- Decision support tool used
- Assessment
- Recommendation and response of patient
- Care advice
- Reason for call back
- Documentation will be guided by caller acknowledgement of first positive expressed symptoms.
- The Triage RN will utilize decision support tools to guide assessment that will be documented.
- The Triage RN will not use abbreviations in documentation.
DEFINITIONS: EMR- Electronic Medical Record
RELATED POLICIES: EMR Downtime
EXCEPTIONS: System downtime will require encounter documentation to be documented in Teams under the Downtime channel and will be entered into Anytime Pediatrics as a late entry.
