Every patient encounter starts with a triage process, often via the telephone. The medical person helps assist the patient in deciding the seriousness of their situation and how to proceed. Triage is defined as the rapid assessment of a patient by a trained personal (usually a nurse) to be sure the patient gets the right attention, in the right location and within a proper timeframe. We have compiled a useful list to help you triage and assist patients safely and effectively.
Make the Patient Feel at Ease
As the nurse triage you are more than likely the first individual the patient will speak with. This is where the patient relationship starts. During the first few minutes of the conversation, the patient is usually guarded and scared. By using a relaxing, soft tone of voice, you are more likely to make the patient feel comfortable. Remaining calm and speaking softly can help the patient let their guard down, and in turn, they will be more likely to open up to you and voice their concerns.
Gather Vital Information Quickly
One of the biggest tricks of the trade to becoming an expert triage nurse is developing a system to gather important key information in a timely fashion. It is important that you are knowledgeable regarding which information and questions are appropriate for a variety of emergency situations. In addition, it is crucial that you use well-established, standardized guidelines such as the Schmitt-Thompson children and adult protocols to ensure that you consider all the possibilities.
Know the Urgency of a Situation
One of the most important roles as the person conducting the triage of a patient is knowing the priority of a situation. This task can be much trickier than it sounds. Some conditions are obviously emergencies in which the patient must be taken in as soon as possible, but other situations are not so cut and dry. This is often the case with telephone nurse triaging, as the patient is likely calling to determine whether emergency medical treatment is necessary. Some common ailments, such as a headache, could also be indicative of a major life-threatening condition. That is why it is always important to ask more questions related to the complaint such as: duration of the headache, intensity, frequency of headaches and location. These assessment questions can give better insight as to whether this is a common headache or a symptom of a more serious condition such as meningitis, a brain tumor or a ruptured blood vessel.
Don’t Diagnose the Patient
When a patient calls for a telephonic triage, they are going to be anxious to find out what is “wrong” with them. They may ask you “what do you think this is?” While you may have a pretty good idea, the doctor is the only one that can legally diagnose. In fact, all states have regulations in place that prohibit nurses from making medical diagnosis. So it is important to practice caution when answering questions and never give the patient a medical diagnosis.
Accurate and complete documentation is absolutely vital to provide high quality care and to reduce legal liability, especially in the area of telephonic triage. Along with the basic information, some important aspects of the encounter that must be included in the documentation are: key pertinent positives and negatives related to the patient’s history, guideline used, recommended disposition, care advice given and clear instructions about follow up.
Save a Life
Telephone triaging is a very risky nursing specialty that requires in-depth knowledge and excellent critical thinking skills. Proper nurse triaging can literally mean the difference between life and death for the patient. That is why expert nurse triaging is so critical to providing safe and effective care. Your goal should be to get the patient to the right place, at the right time as effectively as possible.
What to read next: Telephone Triage: Goals and Process
http://download.journals.elsevierhealth.com/pdfs/journals/0029-6554/PIIS0029655499900544.pdf Telephone Triage and Consultation: An Emerging Role for Nurses; Lynda R. Nauright, ED, RN, Linda Moneyham, DNS, RN, Julianna Williamson, MN, RN