Documentation Policy

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.


  • 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


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.

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