I will try to answer your questions. The computer system is called First Net. Currently we are only using it in triage but it will be integrated into the entire chart eventually. We are getting ready for a huge renovation, doubling the size of the ER, so maybe the changeover will take place then. We do have big plasmaboards with patient info on it. There are no names, but it tells what the chief complaint of patient and the room number, the nurses intials, etc. We are discreet with the CC on the board. We put VB instead of vaginal bleed, SHOB instead of SOB for shortness of breath so folks don't think we are just being rude, FB instead of foreign body, etc. so we don't embarrass anyone. Most of the time laypeople wouldn't know what our abbreviations mean anyway. It will eventually be used for tracking as well, as there is a place to put if the patient goes to x-ray with times, etc. It also tells us how many patients are in the waiting room, and lists how long each patient has been in the system.
As far as absolute info in triage. We get vitals, PCP name, height and weight, LMP if relevent, pertinent medical history, allergies, list of meds including vitamins, herbal preparations, etc., current immunizations, head circumference in infants and of course, chief complaint. With the med list we also include what if anything the patient has tried relative to this complaint, i.e., pain meds, antacids, laxatives, etc. You can get almost all of that info in a few short questions while the BP machine is doing it's thing.
If someone needs to go straight back, the triage nurse accompanies them and starts the triage process, usually hooking them to a monitor and usually the primary nurse will take over before she can finish. We don't have an internal triage nurse but do have a charge nurse who usually does not take a patient load and is available to help. Currently, if an ambulance comes in, we just do the old paper triage note and transfer it to the computer when we have time later. We do have a few portable computers, but it is faster just to use the old fashioned way at this point. Otherwise we chart our triage note directly into the computer in the triage area.
The computer system is more thorough than the paper notes. It takes you thru more phases including method of arrival, i.e. private auto, ambulance, etc. and specifies which ambulance service. If you check yes that the patient is having pain, then you must quantify using the 1-10 scale, then it takes you to an area to describe the pain and tell exactly where..throbbing, sharp, upper left abdomen, etc. It can also be time consuming typing in all the meds and doses if they are not already listed. You could end up writing a book if you are not careful.
Overall it is a good system. We have been using it less than a year so we are getting use to it still. I would like to see laptop type computers instead of the big rolling models that add just one more large piece of equipment into an already crowded space.
I hope this helps. I think our system works great. The last job I had before this one at what I affectionately refer to as the hospital from hell....did not have much of a system at all. The charts were a jumbled mess scattered all over the ER and you never knew where your patients or your charts were. I have never been so glad to exit a place in my life than when I left there. Good luck, you will find a balence somewhere that works for your unit.