At CarePoint you might be asked to triage patients over the phone, during a telemedicine visit, or in-person at the clinic. While this page will focus specifically on phone triage, most of the concepts also apply to other triage settings.

The purpose of phone triage is to:

1. Assess the patient's problem, identifying its nature and urgency. It is your responsibility to figure out what has been going on, how long it has been happening, develop ideas regarding what might be the cause, and determine how serious the situation is.

2. Direct the patient or their caregiver to the appropriate level of care. Is this an emergency? Does the patient need to hang up and call 911? Should the patient be evaluated same day at an urgent care clinic? Is this a problem that can be addressed at their next appointment? Is this something that simply requires reassurance and education?

*The above information was derived from the Core Curriculum for Ambulatory Care Nursing, 4th edition, by Candia Laughlin & Stephanie Witwer. Used with permission of AAACN. Find more information at https://www.aaacn.org/

The American Academy of Pediatrics offers tips & tricks for telephone triage nurses, including:

• Be prepared! Review guidelines and health issues that are common in the patient population you are working with.
• Don't delay documentation. Attempt to document during and immediately after visits.
• Focus on the patient's primary concern; if necessary, keep the patient from getting off track to unrelated issues.
• Keep your references handy and stay organized.

For more information visit: https://www.aap.org/en-us/professional-resources/practice-transformation/managing-patients/telehealth-care/Pages/tips-for-triage-nurses.aspx

Identifying emergent situations and ensuring activation of emergency services is critical in phone triage. The following are the more common emergent diagnoses and associated symptoms, so that you may recognize the situation and immediately tell the patient or caregiver to hang up and dial 911. If the patient or someone with them is unable to call 911, ensure that you have the correct address for the patient and call 911 for them.

See Document below.

Patients will call you with some complaints that can be safely managed at home. Below is a list of several common complaints and some recommendations for self-care at home, along with red flags that indicate the need for urgent medical attention.

*The above information was derived from the Core Curriculum for Ambulatory Care Nursing, 4th edition, by Candia Laughlin & Stephanie Witwer. Used with permission of AAACN. Find more information at https://www.aaacn.org/

Other Sources

The Nursing Process as the Basis for Telephone Triage Video: https://www.youtube.com/watch?v=YOUa3P7aOxk

Common Pitfalls in Telephone Triage, Part 1 Video: https://www.youtube.com/watch?v=6qjh2BiJG3k

Common Pitfalls in Telephone Triage, Part 2 Video: https://www.youtube.com/watch?v=YHOWTLH9m04

American Academy of Pediatrics - Tips for Triage Nurses: https://www.aap.org/en-us/professional-resources/practice-transformation/managing-patients/telehealth-care/Pages/tips-for-triage-nurses.aspx

Medscape - Top Reasons for Primary Care Visits: https://www.medscape.com/viewarticle/908364

Book: The Sports Medicine Patient Advisor, Third Edition (2010), by Pierre Rouzier.

Book: Adult Telephone Protocols, Second Edition (2009), by David Thompson.

Image: https://www.nursingtimes.net/news/primary-care/patient-reminders-effective-at-boosting-vaccination-uptake-18-01-2018/