Writing down a (triage) report

nursejennie76 · Jul 10, 2008

Well I guess I dont understand exactly what you mean by Triage report?? I would include all the things you stated in example #2 but the cough would be the chief complaint, the sputum, lung sounds would be on my assessment,and the meds the patient has taken would be in the medication section. I am a firm believer in not double charting so I guess i think as long as all that info is on the patients ER chart then it does not have to be in the same place??

bluefabian · Jul 10, 2008

Well, I can't really duplicate the entire form with all the sections. Just the way of where and what do we write. Of course, they are sections for documenting for the actions/procedures done on the patient.

Actually, I don't really know how you guys say it. Is it an ER sheet, triage report or nursing documentation. Basically it's a paper (or electronic) documentation on how you chart/list down the nursing actions or assessment done. My question was more on the way to write the report.

Thanks for the reply anyway. Really appreciate it.

Altra, BSN, RN · Jul 10, 2008

I think the previous poster's question reflects the fact that in a typical ER in the US, different nurses have different functions within the department. The nurse who triages a patient on arrival documents differently than the nurse who actually cares for the patient during their time in the ER.

Using your example of a patient with a cough ...

If I were triaging the patient I might include "c/o cough productive of yellow sputum x 5 days, unrelieved by OTC meds, denies chest pain" I would not document lung sounds unless it's something that's audible without a stethoscope ("audible wheezing on inspiration") The triage note is meant to be just enough information to document the patient's chief complaint and route the patient appropriately through the department -- a cough without chest pain and normal vital signs can wait ... a patient with audible wheezing, blue fingertips and a SpO2 of 86% should not wait.

The nurse who is actually caring for the patient will chart a more complete assessment. "Moderate wheezing bilateral bases, +1 edema to bilateral lower extremities" etc.

In general, I'm a fan of more documentation rather than less. I can hear my original preceptor's voice in my head, "Paint the picture of what's going on with the patient!" Inadequate documentation drives me nuts. It is beyond me why/how some nurses can't be bothered to use their assessment skills.

californiaguy · Jul 10, 2008

I am currently switching back to ER and dialysis, and for the first time in almost two years, I am back to ER as a part timer. Back then being a newly graduated, and now having experienced quite a lot of things... I am really wanting to know more on doing a proper documentation on a patient's triage report.
The ER that I am working in right now is a mix of outpatient, dressing bay and the usual cuts, accidents and sometimes emergency cases. What I am not happy with is the quality of documentation that we do. I know that with so many patients switching in and out, we tend to do things on a flash. And a result, what we wrote on the triage sheet can be so simple. Many nurses thought that since the doctor will ask basically the same thing again, there's no need to really ask as much. But I beg to differ as a nurse's report is as important when it comes to legal matter. I can say that what we wrote in the report, gave an impression to the reader what we asses back then.
My question to seasoned ER nurses: how do you do it in your place? And are there are online links where I can see an example.
Here's what some of us might wrote.
Situation: Patient came in complaining of a cough.
Example 1
c/o coughing for five days
Example 2
c/o productive cough 5/7, yellowish sputum
lungs clear on auscultation
fever c chills, generalised body ache
taken pcm II/II @ 6.00 pm, benadryl expectorant for 3/5 with no relief
Well, I guess I could think of a better example but I think that would give you an idea. I try writing as simple and as thorough as possible but it seems hard when you are pressed for time and don't know what to write or prioritize. So I am wondering what you guys are writing on your report. Do you draw diagrams or body parts affected? Like in cut wound: do you write the length/extend of the injury, profuse bleeding, and specify exactly where it is (lower part of index finger, 2 cm across, deep cut wound) (2 puncture wound marks - 2.5cm apart from another).
Thanks for the replies.

Personal experience, I've not worked as a nurse yet, I'm still awaiting nclex results. I'm worried. Triage report really gets down to how detail you want the report to be varies your assessment skills. :scrying: Some nurses in ER are very brief, while others are very detailed down to the point.

If someone comes up with coughing, you might want to mention more detail about breathing. Clear lung's objective, but how about subjective data such as... SOB? (denies) dyspnea? If you're giving a verbal, addition to fever with chills...some might say, elevated T at ....

Personally I would use military time, instead of 6pm.

c/o productive cough 5/7, yellowish sputum (noted)

c/o cough for 5 days, productive yellow sputum.

MassED, BSN, RN · Jul 10, 2008

I am currently switching back to ER and dialysis, and for the first time in almost two years, I am back to ER as a part timer. Back then being a newly graduated, and now having experienced quite a lot of things... I am really wanting to know more on doing a proper documentation on a patient's triage report.
The ER that I am working in right now is a mix of outpatient, dressing bay and the usual cuts, accidents and sometimes emergency cases. What I am not happy with is the quality of documentation that we do. I know that with so many patients switching in and out, we tend to do things on a flash. And a result, what we wrote on the triage sheet can be so simple. Many nurses thought that since the doctor will ask basically the same thing again, there's no need to really ask as much. But I beg to differ as a nurse's report is as important when it comes to legal matter. I can say that what we wrote in the report, gave an impression to the reader what we asses back then.
My question to seasoned ER nurses: how do you do it in your place? And are there are online links where I can see an example.
Here's what some of us might wrote.
Situation: Patient came in complaining of a cough.
Example 1
c/o coughing for five days
Example 2
c/o productive cough 5/7, yellowish sputum
lungs clear on auscultation
fever c chills, generalised body ache
taken pcm II/II @ 6.00 pm, benadryl expectorant for 3/5 with no relief
Well, I guess I could think of a better example but I think that would give you an idea. I try writing as simple and as thorough as possible but it seems hard when you are pressed for time and don't know what to write or prioritize. So I am wondering what you guys are writing on your report. Do you draw diagrams or body parts affected? Like in cut wound: do you write the length/extend of the injury, profuse bleeding, and specify exactly where it is (lower part of index finger, 2 cm across, deep cut wound) (2 puncture wound marks - 2.5cm apart from another).
Thanks for the replies.

definitely would address sputum color and amount, duration of cough (in days, weeks) any edema in ankles, sob with ambulation and fever, worse while lying flat, do you have to prop yourself up at night? Auscultate lung sounds and document findings.

MassED, BSN, RN · Jul 10, 2008

I think the previous poster's question reflects the fact that in a typical ER in the US, different nurses have different functions within the department. The nurse who triages a patient on arrival documents differently than the nurse who actually cares for the patient during their time in the ER.
Using your example of a patient with a cough ...
If I were triaging the patient I might include "c/o cough productive of yellow sputum x 5 days, unrelieved by OTC meds, denies chest pain" I would not document lung sounds unless it's something that's audible without a stethoscope ("audible wheezing on inspiration") The triage note is meant to be just enough information to document the patient's chief complaint and route the patient appropriately through the department -- a cough without chest pain and normal vital signs can wait ... a patient with audible wheezing, blue fingertips and a SpO2 of 86% should not wait.
The nurse who is actually caring for the patient will chart a more complete assessment. "Moderate wheezing bilateral bases, +1 edema to bilateral lower extremities" etc.
In general, I'm a fan of more documentation rather than less. I can hear my original preceptor's voice in my head, "Paint the picture of what's going on with the patient!" Inadequate documentation drives me nuts. It is beyond me why/how some nurses can't be bothered to use their assessment skills.

I disagree. To the extent of triaging, it is a prudent nurse who takes a moment or two to gain enough information to appropriately place the patient in the section they need to be. I would ausculate lung sounds, albeit quickly. The VS are done in triage, so you would know there was a larger issue if the sats were low. While triaging, you note if the patient has edematous extremities, all of which are viewed by the nurse who will be the primary, but more importantly, by the ER doc. This was the way where I work, though now it's a new system where PA's or NP's do a chief complaint and scoot them to where they need to be (and many time inappropriately) then the primary nurse does the triage.

northshore08 · Jul 11, 2008

Sometimes the amount you put in a triage note depends on your ED docs. I don't know if others have seen this, but I have seen docs complain that the triage nurse is documenting too much--makes them have to account for the extra symptoms...

Some just want example #1. If example #2 is what they get, they feel required to work the pt up further.

I claim example #2; work 'em up now. Lowers the 24 hour return rate. So what if it upsets the doc? :cool:

MassED, BSN, RN · Jul 11, 2008

Sometimes the amount you put in a triage note depends on your ED docs. I don't know if others have seen this, but I have seen docs complain that the triage nurse is documenting too much--makes them have to account for the extra symptoms...
Some just want example #1. If example #2 is what they get, they feel required to work the pt up further.
I claim example #2; work 'em up now. Lowers the 24 hour return rate. So what if it upsets the doc?

so what if it upsets the doc is right. If I find it, I document it. I always put together the pieces, from what I observe. If I document: negative sob with ambulation, no edema noted to BLE, then I have noted to that ER doc that I am thinking CHF with a respiratory complaint. That's being a responsible and prudent triage nurse. If my documentation makes an ER doc have to account for extra symptoms that they don't want to, then that's their problem, but I'll document what is found and what is relevant. I won't take any of that from a doc. I've never had a problem for documenting on relevant information regarding a specific complaint, and to do it in about 2-3 minutes.

bluefabian · Jul 11, 2008

Thanks for all the replies.

I too have the problem of whether I am crossing the boundary of the ER doc by asking and documenting too much. It's like, he/she will ask the exact same question as mine, so why bother to do a lot at all. But still, I do come across instances where even docs can miss a thing or two.

Altra, BSN, RN · Jul 11, 2008

I disagree. To the extent of triaging, it is a prudent nurse who takes a moment or two to gain enough information to appropriately place the patient in the section they need to be. I would ausculate lung sounds, albeit quickly. The VS are done in triage, so you would know there was a larger issue if the sats were low. While triaging, you note if the patient has edematous extremities, all of which are viewed by the nurse who will be the primary, but more importantly, by the ER doc. This was the way where I work, though now it's a new system where PA's or NP's do a chief complaint and scoot them to where they need to be (and many time inappropriately) then the primary nurse does the triage.

I don't disagree with what you're saying, and I did note that I personally strongly prefer "more is more" to "less is more" when it comes to charting.

I have not worked in an ER where the triage nurse had the time or the privacy to adequately auscultate lung sounds ... but if I did work in such a place I can guarantee that I would listen to lung sounds for respiratory & cardiac chief complaints to the extent that it did not delay getting a patient out of the triage booth and back into a treatment room where they belong.

I'd be very interested to hear more about how your mid-levels triage (in its literal definition -- "sorting"). Thanks in advance.

MassED, BSN, RN · Jul 11, 2008

Thanks for all the replies.
I too have the problem of whether I am crossing the boundary of the ER doc by asking and documenting too much. It's like, he/she will ask the exact same question as mine, so why bother to do a lot at all. But still, I do come across instances where even docs can miss a thing or two.

you should never second guess yourself based on what the doc may or may not ask. You do your assessments and documentation based on your clinical judgment. Keep in mind that docs sometimes miss things, so your documentation may be a clue to what they have missed.