Navigating Protocols: Steps 3, 4, and 5, is the second part of the series on the 10 critical steps to a successful triage call. During this lesson, you will be paying close attention to the next three steps, Step 3: Collecting a Brief PMH (Patient Medical History), Step 4: Letting the Patient Talk, and Step 5: Documentation. Please review the previous video lesson on steps 1 and 2 before continuing.

While protocols help guide the nurse through the triage process, they are supported by Patient Medical History and documentation. Past medical history adds a layer of additional clinical information to help nurses make sure their patients are getting the best level of care. This information should be collected early in the triage process to help the nurse decide which disposition and plan of care is most appropriate.

This video will walk you through an example of why past medical history is important. You will also learn important questions to ask when taking a patient’s medical history and how to use active listening to determine the patient’s most serious symptom. Finally, the video will discuss documentation. Good documentation will provide information about the patient’s current symptoms and will stand alone if questioned. The video will guide you through the best  documentation practices to create brief, concise, and thorough notes.