Nurse Triage
DCAM Pediatric Clinic
Well- Child Visit Triage
03/20/09
Children
<=2 yrs
≥ 3 years
Teens
Vital Signs
Measurements
Screens
Tests
Questionnaires
In exam room or
Triage room
Lt, Wt, HC
Temp, HR
PPD in exam room
In exam room
Lead & H/H as needed by doctors at
regular intervals
PPD if has risk
BP, Ht, Wt
Temp, HR
Lead if has risk
Hg/CBC if has risk
PPD if has risk
Vision tests as needed by doctors at
regular intervals
Hearing tests as needed by doctors at
regular intervals
Maternal depression: to all moms at
the first newborn visit prior to being
seen by the doctor
M-CHAT: give to the parents either
at the 15 or the 18month visit prior to
being seen by the doctor
Lead screen form: keep in the exam
room for the doctor to use.
TB screen form: keep in the exam
room for the doctor to use.
ACT: keep in the room for the doctor
or given to the family by the nurse?
BP, Ht, Wt
WIC, Camp,
School , Sport
forms
Who fills:
Sharon,
designated LPNs
Shots
In exam room by
doctors’ order
If physicians have forms for parents/patients to fill out (such as new patient history) those can be handed to the families but given the
staffs should not be the responsibility of the nurse to complete. All parent questionnaires should be in room and made available by
nurse who puts patient in room.
Urgent Care / Office Visit Triage
Children
General
(cold, cough…)
Febrile
Asthma
Emergency
before transfer
to Comer ER
Vital Signs
Measurements
Medications
In exam room
In exam room
Temp, weight, BP if >3 yrs
Pulse Oximetry only for patients
with wheezing or difficult
breathing
Medications in DCAM clinic: Tylenol,
Motrin, and Albuterol
Other medications can be ordered from
DCAM pharmacy such as Benedryl,
Prednisone
Rocephin: can be ordered from the pharmacy
Temp, weight, HR and RR
Pulse Oximetry only for patients
with wheezing or difficult
breathing
Temp, weight, HR, and RR
BP if > 3 yrs
Pulse Oximetry
ACT: keep in the room for the doctor or given
to the family by the nurse?
Tests at Office
Test performed in the
office:
Rapid Strep: ordered by
doctors
Tests planned to be
performed in the office
(Meeting on 03/17/09):
Bilirubin
Glucose
Hg
Lead (well check-up)
Rapid Flu*
Urine Dip
Urine Pregnancy
Temp, HR, RR, BP
Must call the ER before transfer
If physicians have forms for parents/patients to fill out (such as asthma control test, ADHD screen or management form…) those can
be handed to the families but given the staffing should not be the responsibility of the nurse to complete. All parent questionnaires
should be in room and made available by nurse who puts patient in room.
* Need guides for nurses
Triage – Screens
DCAM Pediatric Clinic
03/20/09
Screen & Tests
0-35 months old
New patient history*
Screen Time/Location
Comments
Give to the parents of all new patients at the first visit prior to being seen by the
doctor
Bilirubin
As needed for babies with jaundice by the doctors
Newborn Metabolic
Verify the results at 1 month old
Maternal depression*
Hearing
Vision
Blood Pressure
Anemia (Hg)
If the baby wasn’t born at UC, the parents can call IL Health Dept. Lab at
217.785.8101for the result.
To all moms at the first newborn visit prior to being seen by the doctor
If not done in Nursery; should be refereed within the 1st month of life.
Then refer if has concern.
Refer if has parental concern, abnormal red reflex, or prematurity babies with risk
factors.
Measuring if has risk factors.
Lead
For premature infants: 4-6 months old (AAP guideline)
As needed by lab at regular intervals
As needed by lab at regular intervals
TB screen
PPD if has risk factors
Development screen
With each well check-up
Autism (M-CHAT)*
Give to the parents either at the 15 or the 18month visit prior to being seen
by the doctor
3 years old and older
Initial patient history*
Give to the parents of all new patients at the first visit prior to being seen by the
Blood Pressure
doctor
Measuring for all children and teens at each well check-up
Hearing
As needed by doctors’ order at regular intervals
Vision
As needed by doctors’ order at regular intervals
Anemia (Hg)
as needed by doctors’ order at regular intervals
Lead
Lead screen form*
TB screen
TB screen form*
as needed by doctors’ order at regular intervals
Keep in the exam room for the doctor to use.
PPD if has risk
Keep in the exam room for the doctor to use.
ACT if with Hx of
Keep in the room for the doctor or given to the family by the nurse?
Asthma
* If physicians have the following forms for parents/patients to fill out, those can be handed to the families but given the staffs should
not be the responsibility of the nurse to complete. All parent questionnaires should be kept in the exam rooms and made available by
nurse who puts patient in room.
Triage Calls
DCAM Pediatric Clinic
Triage Calls Coverage


Office hours
Off office hours – physicians
Scripting – Triage Calls






Sickness and triage
Sickness and urgent care
Referral
Refill medications
Require WIC, school, sport, camp forms