Health Resources and Services Administration: HRSA PAL 2014

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Policy Area:
Title of Policy: In-person, Walk-Ins, and
Telephone Triage
Effective Date:
Approved Date:
Revision Date:
I.
Subject:
Number:
Page Number:
Approved by:
Rationale for policy:
The telephone provides an invaluable communication link between healthcare providers and
patients and aids in improving patient access to care. Studies have shown that telephone care
reduces unnecessary office visits and patients’ out-of-pocket expenses (American College of
Physicians–American Society of Internal Medicine; 2000: White Paper).
II.
Purpose:
To sort and prioritize telephone calls, improve accessibility to care and use of facility &
community resources (EMS 911).
In-person, face-face triage (includes walk-ins) and telephone triage involves the collection of
pertinent information and initiating a decision-making process that categorizes and prioritizes the
needs of patients seeking care. Triage is a “clinical” service and is a specific and immediate
response a patient’s chief concern.
Telephone triage does not involve making diagnosis by phone but rather it is a process of fact
finding. Telephone triage is used to assess chief concern over the phone and offer
recommendations for the next step of care. Patients calling for appointments may need phone
triage to assess the acuity of their condition.
III.
Scope:
This policy applies to front desk personnel, physicians, Licensed Independent Practitioners (LIPs)
and other licensed or certified practitioners (CHA(P)s. This policy excludes major disaster
situations, mental health services, and community services.
IV.
Procedures:
A.
Personnel Involved
Triage is performed by Physicians, LIPs (NPs, PAs) and other licensed or certified
practitioners (RNs, CHA(P)s). At minimum the triage provider is required to maintain
their Basic Life Support and additional certifications as required per their job description
and position. Additional recommendations include but are not limited to TNCC, ENPC,
and PALS.
At least 2 patient identifiers (name, DOB) are required to verify that the correct chart is
being viewed. Staff will speak directly to patient whenever possible.
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and required federal, state, and accrediting agency standards and regulations
When unable to speak to the patient directly a record of the name and contact information
of the patient or patient’s representative is recorded. Calls are returned to the patient or
representative is made in a timely manner (set time frame).
B.
Hours of Practice Availability
The clinic is open to receive telephone calls from 8:00am – 5:30 pm Monday through
Friday. After hour calls are forwarded automatically to (the on-call provider’s cell/AfterHours Nurse Triage Line for e.g.)
C.
Emergent Calls/Walk-Ins
In the event that a patient or his/her representative presents to or calls the clinic reporting
any of the signs or symptoms on the Emergent Calls List (Appendix A), the following
steps will be taken immediately:
1. When a patient presents to the office, a medical provider will assess patient
immediately to determine urgent/emergent status and course of action.
2. When a patient or his/her representative calls the clinic the caller is to be kept on
line, EMS/911 activated, and clinic medical provider is to be notified
immediately.
D.
Urgent Calls/Walk-Ins
In the event that a patient or his/her representative presents to or calls the clinic reporting
any of the signs or symptoms noted on the Urgent Calls List (Appendix B), the following
steps will be taken:
1. When a patient presents to the office a medical provider will promptly assess
patient to determine if urgent/emergent status/same-day/future appointment to be
made.
2. When patient or his/her representative calls the clinic with signs or symptoms on
the Urgent Call List the medical provider will be given the call immediately to
evaluate and determine the best course of action.
E.
Non-Emergent/Non-Urgent Calls/Walk-ins
When a patient or his/her representative calls the clinic with signs and symptoms that are
not on Appendix A or B and are not deemed to be urgent or life-threatening, a same day
appointment will be made or if patient or representative chooses not to be seen same day
the patient will be offered an opportunity to schedule an appointment at his or her
convenience.
A Telephone Triage Message Form will be completed and sent to the patient’s primary
care or covering provider for timely follow up (set time frame) (see attached Telephone
Triage Message Form). When a patient chooses not to be seen the same day, the patient
will be provided instructions by the provider on where to seek treatment should
symptoms worsen. The instructions include when to call 911 or seek treatment at the
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emergency department, the contact number and hours of operation for the emergency
department or referral facility.
Every business day the patient’s primary care provider must receive a report of the
previous night’s triage activities for review and for follow up as applicable. All
telephone consultation made internally or externally must be entered into the patient’s
medical record.
F.
Documentation Requirements
o All triage notes, telephone triage message forms.
o Date and time of assessment.
o Name of attending triage personnel.
o Presenting patient concern.
o Relevant history.
o Relevant assessment findings.
o Allocated triage acuity e.g., requires emergent, urgent, same day visit.
o If re-triage is necessary the re-triaged assessment along with time completed and
reason.
o Assessment and any diagnostic, first aid, or other treatment measure provided.
o Discharge plan if the patient is discharged from triage, emergency, or any advice
given by telephone.
o Confirmation of patient or representative’s understanding and agreement to plan
of care, instructions, and/or advice.
o Disposition: to home or hospital for example.
G.
Quality Review
Compliance is monitored daily when changes are made to the policy. Once processes are
established monitoring is done quarterly. This policy will be monitored through on-site
medical record audits. Evaluation of triage process is also done through patient
satisfaction surveys.
Triage decisions for appropriateness of actions taken by provider are reviewed quarterly
and feedback is provided to staff and document as an education program (see attached
telephone triage audit form).
This policy is reviewed annually and then circulated to staff to sign and date
acknowledging that it has been reviewed. The protocols and algorithms are reviewed at
least once every 2 years with input from the medical director and medical staff.
CHC Logo Here: This template is intended as a guide to be adapted consistent with the internal needs of your organization
and required federal, state, and accrediting agency standards and regulations
V.
REFERENCES
Health Resources and Services Administration: HRSA PAL 2014-03 Requirements for FTCA #4
Agency for Healthcare Research and Quality (AHRQ)
ECRI Institute
American College of Physicians–American Society of Internal Medicine: Telephone Triage.
Philadelphia: 2000: White Paper.
National Institute of Health (NIH)
Katz, Harvey P. MD, 2001. Telephone medicine: Triage and training for primary care.
Philadelphia: F.A. Davis Company.
National Committee for Quality Assurance (NCQA): Element B
VI.
RESOURCES
http://www.ahrq.gov/professionals/systems/hospital/esi/esi1.html
https://members2.ecri.org/Components/HRSA/Pages/AC_Triage.aspx
https://www.communitycarenc.org/elements/media/files/ppc1a-35triagepolicy.pdf
http://www.wildirismedicaleducation.com/courses/465/index_nceu.html
VII.
Related Policies and Procedures (list all P&P is applicable, otherwise state none in this section.)
CHC Logo Here: This template is intended as a guide to be adapted consistent with the internal needs of your organization
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Appendix A
Emergent Calls List: EMS/911
If patient presents to clinic complaining of any of the following symptoms, request assistance immediately from
medical personnel and call 911:
If you receive a call from a patient or patient representative stating any of the complaints below, keep caller on the
line and have someone activate EMS/911:
Note: list is not intended to be all inclusive but rather a guide for triage.
Airway –compromised or obstructed
o Choking
o Neck or spine injury
o Croup with cyanosis in any infant of child
A. Breathing problems – severe respiratory compromise
o Difficulty breathing (from any cause),
o Difficulty speaking, or swallowing
o Near drowning
o Acute allergic (anaphylactic) reaction with respiratory difficulty (food, bee sting,
medication)
B. Circulation- suspected or impending shock
o Cardiac arrest
o Any chest pains suggesting possibility of heart attack, chest pain with or without discomfort of the jaw,
arm, neck pain and or heaviness in chest
o Uncontrollable bleeding
o Acute allergic (anaphylactic) reaction with respiratory difficulty (food, bee sting,
medication)
o Poisoning or overdose of medication with change in mental status, signs of shock, or any respiratory
difficultly
C. Disability an d/or neurologic impairment or paralysis
o Convulsion (seizure)
o Inability to walk, talk, or move limb
o Any neurologic symptoms suggestive of stroke: Sudden numbness or weakness of the
face,
arm, or leg (especially on one side of the body), sudden confusion, trouble
speaking or
understanding speech; Sudden trouble seeing in one or both eyes,
sudden trouble walking,
dizziness, loss of balance or coordination, sudden
severe headache with no known cause
o Coma or unconsciousness
o Head trauma with change in normal behavior such as extremely hard to arouse, excessively
fussy, loss of consciousness, confusion
o Diabetic hypoglycemic reaction with mental confusion and inability to take oral glucose
D. Other
o Severe trauma (e.g., fall from high place such as a tree or building window)
o Obvious fracture and/ or bone protruding from skin
o Neurological symptoms such as seizures or
o Head Trauma with behavioral changes and or recurrent vomiting
o
o
o
o
Severe pain, unable to walk
Suicide threats or attempts
Sexual assault
Abuse
CHC Logo Here: This template is intended as a guide to be adapted consistent with the internal needs of your organization
and required federal, state, and accrediting agency standards and regulations
Appendix B
Urgent Calls List
Immediate appointment – As soon as possible (within 2 hours)
Note: these are just examples. Judgment is required based on suspected severity, patient or parental anxiety, or
potential consequences of conditioning worsening if not seen immediately.
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Acting very ill (very irritable or lethargic)
Severe or increasing abdominal pain or pain localized to the lower abdomen
Acute allergic reaction (e.g., hives) without respiratory symptoms or signs of anaphylaxis
Extremely anxious parent or acutely depressed patient
Burns
Sudden change in any condition and symptoms worsen
Croup symptoms in infants less than 6 months of age
Fever in infant under 3 months of age
Fever 104° F or greater
Purple or blood colored rash
Testicular Pain
Severe Pain of any kind
Inconsolable crying in child or infant
Patient or patient representative has called more than one time about same complaint in last 24-48 hours
Appointment same day (within 8 hours)
Note: these are just examples. Judgment is required based on no risk or low risk form not being seen immediately
and patient comfort.
□
□
□
□
□
□
□
□
□
Diarrhea
Earache
Fever uncontrolled by treatment
Joint pain or swelling
Excessive urination and thirst
Pain or burning on urination
Skin infection
Sore throat
Swollen glands
Future appointment (within 3 days or less)
Note: Patients are very reluctant to wait, so the appointment should be given as soon as possible, depending on the
time available and the nature of the problem. These are examples to serve guidelines for similar chronic problems.
□
□
□
□
□
□
□
Recurrent anxiety attacks
Mild chronic depression
Diagnostic problems with non-acute symptoms that have been present for a long time (e.g., recurrent
headache, chronic abdominal pain)
Emotional or behavioral problems
Enuresis (bedwetting) in a child over 4 years of age
Growth problems
School problems
CHC Logo Here: This template is intended as a guide to be adapted consistent with the internal needs of your organization
and required federal, state, and accrediting agency standards and regulations
Telephone Triage Algorithm
Patient Calls
By Receptionist
Call is
Answered
By Automated
Telephone System
Call is
transferred to
designee
By Designee
Answered
Questions are
posed to patient
By Voicemail
Designee listens to
message and calls
patient back
Message is left for
practitioner
Established
triage p rotocols
To informal
protocols
Told they will
receive a call back
Designee
researches issue
Designee
Patient receives
call back
physician
patient is told if condition worsens to call back
Call 911, or go to the emergency department
at a hospital.
Medical Mutual Insurance Company of Maine's "Forms" are offered as reference information only and are not
intended to establish practice standards or serve as legal advice. MMIC recommends you obtain a legal
opinion from a qualified attorney for any specific application to your practice.
CHC Logo Here: This template is intended as a guide to be adapted consistent with the internal needs of your organization
and required federal, state, and accrediting agency standards and regulations
Telephone Triage
Documentation Audit
Indicates who took the
message
Date Present
Time Present
Patient Name Present
Problem/Patient Complaint
Current Medications
Caller’s Name if Not Patient
Relationship to patient
Other Medical Problems
Allergies
Patient’s phone or cell #
Patient’s Age
Weight
Patient’s Work Phone #
Pregnant?
Primary Care Provider
Problem/Patient Complaint
Medication refill per policy
Medication – name and dose
Pharmacy Name
Pharmacy Phone #
Follow up instructions given to
patient
Treatment Plan
Appropriate Clinical Advice
Given to Patient
Patient Verbalizes
Understanding of Treatment
Plan and/or Clinical Advice
Given
Patient Understands to Call
Back if Symptoms Worsen or
to Call the ER if the Office Is
Closed
Call Returned By Name of
Caller Documented
Date/Time of Call
Documented
Provider Consulted
Documented
Provider Review/Signature
Present
Date/Time of Provider
Signature
Page 1/2
MRN
MRN
MRN
MRN
MRN
CHC Logo Here: This template is intended as a guide to be adapted consistent with the internal needs of your organization
and required federal, state, and accrediting agency standards and regulations
Summary Results of the Telephone Triage Documentation Audit:
Results Reviewed with the Following Staff Members:
Process Improvements Discussed:
Review/Education Presented By: Date:
Page 2/2
Medical Mutual's "Forms" are offered as reference information only and are not intended to establish
practice standards or serve as legal advice. MMIC recommends you obtain a legal opinion from a
qualified attorney for any specific application to your practice.
CHC Logo Here: This template is intended as a guide to be adapted consistent with the internal needs of your organization
and required federal, state, and accrediting agency standards and regulations
CHC Logo Here: This template is intended as a guide to be adapted consistent with the internal needs of your organization
and required federal, state, and accrediting agency standards and regulations
Telephone Triage Message Form
Message taken by:
Date:
Patients Name:
DOB:
Time:
Age:
Allergies:
Callers Name (if not patient):
Callers relationship to patient:
Patient Chief Concern/Problem:
Current Medication:
Past Medical History:
Primary Care provider:
Patient can be reached at:
□ Home
□ Cell □ Work
Home #:
Weight:
Medication refill request?
Cell #:
YES
NO
Is patient pregnant?
YES
NO
Work #:
Name of Medication(s) continued:
Name of Medication:
Pharmacy Name:
Pharmacy Phone #:
Pharmacy Fax#:
Page 1/2
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Follow Up:
□
Emergency department referral
□
Given instructions over phone
□
Prescription called in
□
Refill medication made to pharmacy
□
Appointment made for ___________ at __________ AM/PM
□
Referral to _______________________ made on _______________
Communication with Patient
Treatment Plan:
Clinical Advice Given to Patient:
Patient verbalizes understanding of treatment plan and/or clinical advice given.
□ YES
Comments:
Patient understands to call back if symptoms worsen or call the ED if office is closed. □ YES
Comments:
Call Returned by:
Date/Time:
Provider consulted □ YES □ NO
Provider Signature:
Date/Time:
Page 2/2
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