Guideline Choice
Something feels funny in my chest.
Chest Pain (Adult)
This must be given with all recommendations except for home care.
The disposition timeframe
PHI required on all Red Flag calls.
Full name
DOB
Callback number
Address - Is there another adult with you right now? If alone, what is your address?
Questions to ask to assess: LOC
Have you fainted or lost consciousness since your symptoms began?
This must be documented clearly for ONSET of symptoms in SOARS.
Timeframe: days, hours, minutes
19yo with a red swollen breast.
Breast Symptoms (ADULT)
2 required questions to ask after giving a Go to ED Now recommendation.
Which hospital will you go to? AND who will drive you? (Remember to document both)
PHI required on all NF calls.
What is the name and DOB of the patient? What is your callback number? What is your current physical location? If urgent sounding symptoms: Is there another adult with you right now?
Questions to ask to assess: Severe difficulty breathing.
Use clinical judgement and critical thinking to assess how they sound in addition to probing questions like: Are you having any difficulty breathing right now? What does it feel like? Is your breathing keeping you from doing anything?
This should be documented in ACTION box of SOARS.
ANY intervention used to treat the symptom: homeopathic, OTC, street drugs, massage/heat/cold/changing position, drinks/foods etc. Ask "What did you do to treat your symptoms?" and document everything they did.
Car accident 3 days ago, neck pain that started 24hrs ago, bruise on chest and abdomen from seat belt.
Motor Vehicle Accident (Adult)
This is how you sound confident in the recommendation. (Even when you think it is higher than necessary).
(Based on my assessment/based on what we discussed,) My best recommendation is....
What we should ask if the caller is NOT the adult patient.
Are they there so I can speak to them directly? If they are not there: Can we call them?
Questions to ask to assess: Severe pain >1hr.
Probing is important. What is your pain level right now? How long has it been this bad? What is the pain keeping you from being able to do?
Support this PTS: Intussusception suspected (brief attacks of severe abdominal pain/crying suddenly switching to 2-10 minute periods of quiet) (age usually < 3 years).
Child woke up screaming, red faced, back arching. Repeated episodes of crying and unable to be soothed by parents, 8min of calm between episodes of crying lasting 5-10min or so, cycle repeating for 35min
5yo, hx asthma, cough, wheezing, on prednisone taper, not getting better.
Asthma Attack on Steroid Follow-Up Call
Acceptable locations for PCP triage
Telehealth, UCC, PCP office if open, Paging if available and office is closed, ED if other locations are closed/unavailable.
CALLER WITH PATIENT: When caller hands the adult patient the phone for consent or to initiate triage, what should we do first?
Reintroduce yourself and ask: What is your full name and DOB?
Questions to ask to assess: Shock
Are you able to stand and walk without assistance?
Question(s) asked, information provided (Summary), and source (URL or Healthwise article.) No symptoms present. Triage offered and declined.
12yo boy w/ADHD, jumping on a trampoline, fell off, unwitnessed, no visible injury, not his usual self and wants to nap all afternoon
Head Injury (Peds)
What response would you give if patient with a 'See in 3 Days' recommendation states "I am going to the emergency room right now."
The good news is that based on what you told me, your symptoms are not emergent, and you can wait to be seen until the office is open. Another option would be an urgent care, they will be able to see you much faster and it is usually costs much less.
Questions to ask if caller is not at home or does not know the address of where they are. (Outside, in a hotel, at work, driving, at a store/pharmacy).
What is the name of the [where they are]? What road/crossroad/exit are you near? What other landmarks can you see?
Questions to ask to assess: Lethargy in a child
What are they doing right now? Are they able to sit/stand/crawl/walk (age-appropriate ability) independently? Infant: are they alert, moving their limbs/head, crying, eating?
Required documentation to include when paging or re-paging
For initial page: Use Nursing Note dropdown and complete needed info.
After page completed, add addendum including: Who was paged? How were they paged? When were they paged (include time zone)? Why were they paged?
Re-page: Addendum including all of the above AGAIN.
Page log: Check box for "gave message" once you have spoken to the on-call.