When it comes to documenting triage calls, there’s always a fine balance between effective communications and liability risk. Nurses want to – and need to – effectively communicate information and directions to patients and those who may see their notes after the call. However; triage nurses must also cover themselves when it comes to liability. For additional information on clinical documentation, please visit the TriageLogic Learning Center.
So, what elements make up good call documentation? Here are three tips to make sure your calls are well documented:
Make your communication clear – read your notes out loud and ask yourself, would this make sense to anyone else who reads it? Have I used the appropriate words? Does it have a definitive beginning and end?
Make your communication concise – think about what your narrative will look like to others. Not only to the next caregiver, but six months or a year later when it may need to be reviewed. Is it direct and to the point?
Make your communication credible – use appropriate terminology, punctuation and abbreviations. Make sure your documentation would be believed by others to be written by someone who is knowledgeable. Always stick to the facts and avoid jargon or slang. If a patient says she has a tummy ache, put that information in quotes so it’s known these were the patient’s words. Nurse triage documentation is not the place for personal views.
It’s important to remember that a nurse is judged by a reasonable standard; what a reasonable nurse would have done under the same or similar circumstances. TriageLogic telephone triage nurses use the Schmitt-Thompson protocols to help fulfill the need for reasonable care. See the most recent guidelines and the benefits of protocols for both children and adult triage.
Every nurse wants to provide the best care – perfect care. But perfect care is not what the law requires – the law requires that a triage nurse provide reasonable care. Clear, concise and credible documentation is always a best practice.
To find out how TriageLogic can help with your telephone triage needs, please call (855) 734-4463.