Triage Nurses: what are your favorite phrases to document?

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I start triaging patients in the waiting room soon and I'd love to make myself a quick reference list of phrases to use to document pt condition quickly/succinctly. Some common phrases I've seen from my co-workers include: "No apparent distress," "Pink, warm, dry," "Using cell phone," "ambulated to desk."

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Specializes in Adult and pediatric emergency and critical care.

Just write what reinforces the patient being sick or not sick.

Be careful of certain phrases unless they are actually appropriate, do I care that the patient complaining of an ankle injury sends a text during triage? No.

Do I care that the patient who complains of migraine with photophobia is swiping on tinder? Yes, and I will be documenting that.

Hopefully your hosptial has some kind of triage class or orientation specific to triage.

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Agree. Be extremely careful about documenting things that, although factual, are also judgmental by the fact that they're irrelevant. Documenting in those instances makes it very obvious that you were trying to convey a certain spin.

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For children - document what I see that helps convey their general condition:

Very active; hopping and skipping without difficulty

Actively investigates surroundings/triage room

Runs into triage area without difficulty

Interacting appropriately with caregivers/parents; comforted by parents

Verbal/inquisitive

Animated; playing with _____ (toy, parent's phone, etc)

Lifts self/hops/jumps/climbs up onto stretcher without difficulty

Vigorous cry

Wet/saturated diaper in place - important to note - but I am careful to make sure this is conveyed as a hydration assessment, not a parenting judgment (since it in no way is meant like that)

Etc.

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Specializes in Adult and pediatric emergency and critical care.

Let me clarify that the cellphone comment or similar documentation (eating Cheetos/Mountain Dew, laughing, et cetera) needs to be relevant to the patient's complaint.

For example if the patient complains of photophobia and are engaging in bright/visual stimulation then I think that it is appropriate to document that, if the patient has a medical problem and is just letting their family know that is appropriate for the patient to do.

If the patient complains that they had red emesis and are eating flaming hot Cheetos in triage then this is relevant, the same as parents who report a melena stool in their child but were feeding them blueberries earlier in the day. If the patient complaints of RLQ pain and is eating Chester's finest there is a lot less relevancy to the finding.

If the patient's behavior (whether it be cell phone use, yelling/cursing at staff, et cetera) is truly disruptive to the patient assessment, which generally is far more rare than people think, then that should be documented as well. In these cases I would document something along the lines of 'patient yelling/cursing at security and nursing staff in waiting room, patient continues this despite being asked to stop, this RN's exam limited by this.' This isn't just a matter of making the patient look bad but if they end up having a complaint that couldn't be explored during triage you should have good medico-legal documentation of it. For example it is not uncommon for our psych patients who are manic to not be able to have a great history, and it isn't until we have medicated them that they have expressed that they are currently being treated for UTI, PNA, and so on. As infectious disease can very much contribute to AMS and exacerbation of mental health conditions we should have a good reason why we didn't treat their infection on initial presentation to the ED.

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"She been spittin' up collards all evenin.'"

"I done had this since______."

"I think I got somethin' in my butt."

"I'm outta Klonopin."

"I know you're not 'sposed to, but I took my friend's medicine."

"I've had a [rhymes with donor] all day."

"Mother [appreciating]" as perhaps the only qualitative measurement.

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Some of the funnier ones are "pain 10/10, eating chips" etc. Not triage related, but one time a patient had left without telling anyone and the nurse wrote "patient not in room, Mediao magazine on bed," as that was apparently what the patient left behind.

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Specializes in Trauma, Teaching.

We have separate subjective and objective boxes: so for subj I report what their complaints are, history relevant to the complaint. In obj, usually " alert, cooperative, sits upright, amb with steady gait, no resp distress" for the walky/talkys. Describe the wound, the limb, the deformity, circulation distal to the complaint ("broken arm/shoulder/wrist") with radial pulse and cap refill. Or: "lethargic, breathing hard, pale, sits slumped in wheelchair, charge nurse notified"

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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.

Favorite triage comment ever: "patient lying on own yoga mat in waiting room." Cracks me up every time I think about it!

I try to stick to objective commentary. Direct quotes are fun, too.

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Thanks for all the feedback! I appreciate it!

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Specializes in Urgent Care NP, Emergency Nursing, Camp Nursing.

"Patient is well-known to the department"

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Specializes in clinical pathways - ED, home infusion, IT, lab.

(stated but not charted) "positive Cheetos sign"

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Specializes in ED.

"Patient drove self to ED."

"Pt reports "severe" vomiting x12 hours with approximately 20 episodes of emesis since onset of s/s. Pt actively / not actively vomiting at this time."

For kids, I chart something like "Pt does not appear to be in in any acute distress / discomfort. Breathing is even and non-labored."

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