Gavel and stethoscope rest on a medical binder beside a computer keyboard.

Legal Perspective on Telephone Nurse Triage Documentation and Tips for Success

There’s no question that telephone triage nurses provide a valuable resource for patients seeking guidance on medical care. But like all areas of healthcare, they must also understand the legal responsibilities and liabilities involved in telephone nurse triage documentation. Here are the main points they must keep in mind to provide the most accurate dispositions and avoid legal or negligence issues:

They don’t make diagnoses

It’s important to remember that triage nurses do not diagnose patient symptoms, nor should they claim to. Their role is to have an empathetic ear for listening to patients and to utilize standardized nurse triage protocols to provide dispositions on recommended care. The video to your right demonstrates how nurses select the appropriate protocols.

They document patient calls thoroughly

When someone calls a triage line, they’re greeted by an answering service operator. This operator makes a note of the patient’s reason for calling and collects some initial information about the symptoms that the patient is currently experiencing. This allows a nurse to determine which patients may require immediate calls because they may be more urgent. The nurse then proceeds to call those patients back to verify the information provided and evaluate their symptoms.

All documentation by the nurse must be concise, using medically approved terminology (i.e., no personal shorthand or slang) that allows other medical professionals to understand what they’re reading without ambiguity. The only exception to this would be if the patient were to use specific slang that the nurse felt needed to be included in their notes, as long as that information is put in quotes. Documentation must be strictly factual and exclude any personal judgement.

Telephone triage nurses must also be trained to discern the information that’s necessary to include from that which isn’t, as patients have a tendency to provide details unrelated to their call, or to underreport their symptoms.

They take steps to avoid potential negligence

There will be times when negative outcomes occur after patients speak with telephone nurse triage. What’s important is that triage nurses can prove that they did everything according to their training, protocols, and documentation — including when they have to manage difficult calls like in this video.

Part of that means understanding what factors must be proven in order for a jury to reach a verdict of negligence.

  1. A duty to the patient. This is established the moment an operator or triage nurse picks up the phone and begins speaking with a caller.
  2. A breach in duty. In other words, did the nurse neglect a step in their triage (“omission”), or did they perform an action that they should not have (“commission”)? At this stage, they’re judged against a reasonable standard, which means comparing their actions to what a reasonable nurse would have done in the same situation.
  3. A proximate case. Can a link be established between a patient’s injury or negative outcome and what the triage nurse either did or did not do? If so, the case can move forward.
  4. Damages. Did the patient suffer irrevocable harm from a nurse’s action or inaction? If so, compensation may be awarded.

They follow a routine for negative responses

Should negative responses be documented when triaging a patient? That may depend on the policies of your organization — but it must also be an established routine that everyone follows in order to avoid the perception of wrongdoing. That way, if one patient’s interaction with a nurse is questioned, any nurse on your team can attest that the documentation was done accordingly to the standards of the practice. Nurse triage software offers buttons to make documentation easy and accountable.

They don’t change their notes

Once triage notes are made in a patient’s chart, triage nurses should not edit them. Doing so may also create an impression of wrongdoing. If a nurse thinks their documentation is unclear, it’s best if they involve their in-house risk manager.

If you have questions about these points, or to add nurse triage to your practice, contact us. Our RNs are available to answer your patient callers 24/7, utilize the most up-to-date protocols from Drs. Schmitt and Thompson, and integrate their documentation directly with your in-house EMR.

Learning Center: courses and videos, learn more about telephone triage

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