Protocol Nuances

Protocol Nuances  

  • 2 or more protocols  used in assessment - provide care advice from each protocol. Disposition must be one of highest acuity. For example, if one protocol disposition is Home Care and the other is See HCP in 4 hours, you must instruct the patient to be seen within 4 hours.  


  • Pediatric patients age 18 can be triaged as peds or adult, patients with disabilities over the age of 18 and under pediatric care can be triaged as peds 


  • Triage Nurse Must Triage Newborns 

  • Less than 4 weeks of age, who have not established care with PCP.  

  • In EMR, patient will most likely be found under Baby Boy/Girl (mom's last name). For example, Baby Girl Jones.  


  • Newborn Guidelines up to 3 months 

  • Rash and birthmarks  

  • Normal reflexes and behaviors 

  • A pink or peach color to the urine found in some normal newborns 

  • Bottle and breast feeding questions 


  • Breastfeeding - Mother's Medicines and Diet - allows mom to call the pediatric office with medication questions as it may affect her baby (the patient). If mom is calling her PCP or Ob/Gyn she would be the patient 


  • Cough/Cold symptoms in a newborn - Use Cough protocol - See PCP in 24 hours for cough in patient less then 3 months old.  


  • Shortness of breath is listed under Breathing Difficulty in protocols 


  • BP Concerns - see Information Only protocol (see physician in 3 days if no history and no symptoms) 


  • Complex Disease  protocol for patients with chronic conditions and symptoms related to the condition 


  • Already left for hospital/UCC - No contact or Duplicate Contact Call Protocol 


  • Critical Labs - PCP Call/No Triage Protocol 


  • Approved Medications list may be used for OTC medication recommendations not found in specific protocol care advice 


  • Fever Under 3 Month 100.4 or greater must be evaluated UNLESS recent vaccinations and feeding well/normal activity - see immunization reactions protocol 


  • MVA or Fall - Use Head injury protocol for pediatric patients (also for golf cart, 4-wheeler, and other ATV injuries) 


  • Recent medical visit or hospitalization - if new symptom/unrelated triage under protocol for specific symptom 

  • If recent illness/injury - must be within 48 hours 


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