ER Nurse - Compiling Triage Note/Story, Tips?

[hillimicha]

Hello all,

I am a new Grad RN and getting my feet wet in the ED as a new nurse.  A lot of things I love and understand about the unit thus far; however, one thing I am hoping someone can give me a better picture on is compiling a better Triage Story/Note when a patient comes into the ED, specifically for individual circumstances. 

For example, when a patient arrives EMS, I need to talk to EMS and get the story alongside getting the patient on the monitor and doing my primary assessment.  I take the information I gather and then compile my 'Triage Note' that the doctor will likely read over before coming into the room, as well, the doctor might ask me a couple of questions they would like to know from EMS.  As it stands, when left on my own, while I can compile and ascertain information that people are looking for, I am often a bit scatter brained about it and some of the doctors are pretty to-the-point.  I'd like to be more optimized when talking to them. 

My big conundrum is knowing what bits of information are important for a given circumstance.  For example, if someone comes in due to a fall, I know to ask did they have LOC?  Are they on anticoagulants?  Do they remember anything before the fall (such as warning signs or potential causes), and are there signs of head trauma etc. etc.  But what about the other situations?  Also, are there bits of information that you are looking for from EMS that is often missed?  Is there some sort of resource out there that anyone recommends for New ED nurses to optimize their information gathering of a patient when they arrive into the ED for specific circumstances like I mentioned above?