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
