Need help re: triage assessments

[ValleyRN]

Hello! I need to know what you all are doing in your ER's. My NEW ER manager has recently removed the assessment from the triage process. Thats right, no assessment of distal CMS for lower ext injuries, no neuro baseline check on HA's, no bowel sounds or specifics documented on abdominal pains. This has me very confused. How do we back up our acuity levels assigned to pt's if we do not document even a condensed assessment by exception?? I am, of course, referring to those pts that are send to the waiting room to await bed availability. The charge nurse is ultimately responsible for ensuring pt flow and appropriateness of care. I cant understand how to do this when I come in at 7pm to 10-15 waiting pt's with various complaints who have been waiting and I have noting but VS, HX, and complaint. I need advice and resources to take to my Mgr. Where are the standards of care for ER?????

[ERNurse752, RN]

How are you supposed to triage people without assessing them? Makes no sense. I mean, you don't have to do a full head-to-toe on everyone, but you DO have to assess. Chief complaints mean NOTHING without some kind of physical assessment. Sounds pretty dangerous to me!

What has this manager said you're supposed to do, exactly? Just take their chief complaint and assign them to a room and forget about them based just on that?

[MajorDomo]

The ENA has Standards of Emergency Nuring Practice. Look under standard VII, it includes subjective and objective data to be included in the triage assessment. Also, depending on which triage system is used, there is a lot in information on the five level ESI system to fall back on.

Ran into similar situation at my job, except it was patient education at triage (my NM is a former ward nurse).

Hope this helps

MajorDomo

[tridil2000, MSN, RN]

Hello! I need to know what you all are doing in your ER's. My NEW ER manager has recently removed the assessment from the triage process. Thats right, no assessment of distal CMS for lower ext injuries, no neuro baseline check on HA's, no bowel sounds or specifics documented on abdominal pains. This has me very confused. How do we back up our acuity levels assigned to pt's if we do not document even a condensed assessment by exception?? I am, of course, referring to those pts that are send to the waiting room to await bed availability. The charge nurse is ultimately responsible for ensuring pt flow and appropriateness of care. I cant understand how to do this when I come in at 7pm to 10-15 waiting pt's with various complaints who have been waiting and I have noting but VS, HX, and complaint. I need advice and resources to take to my Mgr. Where are the standards of care for ER?????

are you using the new 5 level system?

i zone in on the chief complaint and assess that system and briefly address it in the objective note.

[lblondie1128]

we do a minimal focused assessment. of couse we ask questions ie; nvd, weakness, etc depending on cc. but for ext injuries, definitly chart pms, now I must say I dont listen to bowel sounds, and if i hear audible wheezing, it is noted, but on resp, if i can hear it or sats low, im going to be finding me a bed quickly. for alot of cc i chart no distress noted, or some other canvassing statement based on vs and gen appearance. If my assessment findings no matter what they are, are not going to make a difference in pt wait time, its generally not done. Ie: ext injury c -p+m-s,,, i need to get him back more quickly.