Quote from vampireslayer
So what REALLY HAS to be done at triage, and what can wait until the patient gets a bed?
I honestly don't know what legally has to be done per JCAHO/etc, but this is what our triage screen has:
-free text box for chief compalint
-full vitals (t/p/r/bp/pulse ox)
-pain assessment (2 options: pain scale or full pain assessment... pain scale takes you to a 0-10 screen where you click the number, and is only supposed to be used for folks with 0 pain... full pain assessment takes you to a picture of human body, click where their pain is, takes you to a screen where you [[describe pain [sharp, dull, throbbing, burning, cramp, etc] and mark either radiation [to ______] or no radiation, intermittent or constant, and that you educated them on pain control, and set a goal (0-10) for their pain]] seems like a lot but it's a lot of click to mark a box and move on -- goes quickly
-onset of problem
-who info is obtained from (pt, parent, relative, friend, amb record, NH record, police)
-on medications or no medications (click one or the other)
-medical hx (brings you to a list and you double click dx's to add to history)
-OB hx (LMP, G/P/A, etc -- very simple and concise)
-acuity (acute, emergent, urgent, non-urgent)
-triaged to... main ED, fast track, waiting room, or discharge from triage -- takes you to a screen that basically says "triaged to room ___", pt instructed/assisted to undress, transported via (stretcher, wheel chair, ambulatory)
I think that's all. I personally think it's pretty simple -- of course there are things that aren't necessarily necessary (i.e. OB hx unless having female sx) and in the free text box you can write as little or as much as you want. Some triage nurses are too vague ("pt presents with abdominal pain"), while some are a little better ("pt presents with abdominal pain x3 days off and on, exacerbated with food/liquid. pain started in ruq and has become generalized; abdomen firm and tender x4 quadrants, hypoactive bowel sounds x4 quadrants. nausea and vomiting for past 8 hours. unable to keep food or fluids down. vomiting at time of assessment.") or whatever... and some tell a life story. I've never heard anyone complain about our triage screen...
hope that helps!