Determine the nature and urgency of patient's condition
3
Record patient's vital signs
4
Ask preliminary questions about patient's health history
5
Review patient's medications and allergies
6
Perform physical examination of the patient
7
Approve Initial Findings
8
Implement immediate care as necessary
9
Prepare patient for further tests
10
Approval: Medical Tests
11
Evaluate test results
12
Determine need for admission
13
Approval: Admission
14
Communicate findings with other healthcare providers
15
Draft initial treatment plan
16
Approval: Treatment Plan
17
Educate patient on follow-up care
18
Coordinate discharge or transfer of patient
19
Document all procedures and findings in patient's records
20
Approval: Patient Records
Establish initial contact with patient
Initiate contact with the patient to establish a rapport and gather necessary information. Use a friendly tone and ask open-ended questions to encourage communication. Record the patient's contact details, preferred communication method, and any special needs they may have.
Determine the nature and urgency of patient's condition
Assess the patient's condition to prioritize the level of care needed. Ask questions about symptoms, duration, and severity. Determine if immediate attention is required or if the patient can wait for further evaluation.
1
Fever
2
Chest Pain
3
Difficulty Breathing
4
Nausea
5
Headache
1
Mild
2
Moderate
3
Severe
1
Severe Pain
2
Bleeding
3
Loss of Consciousness
4
Shortness of Breath
5
Allergic Reaction
1
Mild Pain
2
Soreness
3
Runny Nose
4
Minor Cuts
5
Fatigue
Record patient's vital signs
Measure and document the patient's vital signs to obtain baseline information about the patient's overall health. This information will assist in monitoring the patient's progress and evaluating treatment effectiveness. Ask the patient to relax and ensure they understand the importance of accurate readings.
Ask preliminary questions about patient's health history
Gain a preliminary understanding of the patient's health history to identify potential risk factors or underlying conditions. Use an empathetic tone and ensure confidentiality to encourage the patient to disclose relevant information.
1
Under 18
2
18-35
3
36-50
4
51-65
5
Over 65
1
Heart Disease
2
Diabetes
3
Cancer
4
High Blood Pressure
5
None
1
Heart Disease
2
Diabetes
3
Cancer
4
High Blood Pressure
5
None
1
Current Smoker
2
Former Smoker
3
Non-smoker
1
Regular
2
Occasional
3
None
Review patient's medications and allergies
Identify any medications the patient is currently taking and ascertain any known allergies. Use a non-judgmental tone and ask open-ended questions to encourage disclosure of relevant information.
Perform physical examination of the patient
Conduct a thorough physical examination to gather objective data on the patient's overall health. Explain the process to the patient and ensure their comfort and privacy. Use a gentle tone and maintain professionalism throughout the examination.
1
Head and Neck
2
Chest and Lungs
3
Heart
4
Abdomen
5
Extremities
Approve Initial Findings
Evaluate the initial findings from the triage assessment to determine the appropriate course of action. Consider all the information gathered about the patient's condition, vital signs, health history, and physical examination. Collaborate with other healthcare providers if necessary.
1
Requires Immediate Medical Attention
2
Can Wait for Further Evaluation
Implement immediate care as necessary
Provide immediate care based on the patient's condition and approved findings. Utilize your medical expertise and available resources to deliver prompt and effective care. Document the care provided and any medication administered for future reference.
Prepare patient for further tests
Inform the patient about the need for further tests to gather additional information or confirm initial findings. Explain the purpose of each test, the procedure involved, and any special instructions or preparations required. Address any concerns or questions the patient may have.
Approval: Medical Tests
Will be submitted for approval:
Prepare patient for further tests
Will be submitted
Evaluate test results
Review and interpret the results of the tests performed on the patient. Analyze the data obtained and compare it with established reference ranges or criteria. Consider any relevant clinical guidelines or best practices. Determine if further tests or actions are necessary based on the results.
1
Normal
2
Abnormal
Determine need for admission
Assess the patient's condition and available resources to determine if admission to a healthcare facility is necessary. Consider the patient's medical status, support system, and the level of care required. Collaborate with healthcare providers involved in the patient's care to make an informed decision.
1
Yes
2
No
Approval: Admission
Will be submitted for approval:
Determine need for admission
Will be submitted
Communicate findings with other healthcare providers
Effectively communicate the findings from the triage assessment to other healthcare providers involved in the patient's care. Use clear and concise language, ensuring all relevant information is included. Collaborate with the providers to ensure a coordinated and comprehensive approach to the patient's treatment.
Draft initial treatment plan
Create an initial treatment plan based on the triage assessment findings. Consider the patient's condition, test results, and any necessary interventions. Ensure the plan is comprehensive, realistic, and aligns with the patient's goals and preferences. Document the plan for easy reference and communication with other healthcare providers.
Approval: Treatment Plan
Will be submitted for approval:
Draft initial treatment plan
Will be submitted
Educate patient on follow-up care
Provide the patient with information on recommended follow-up care. Explain the rationale behind each step and address any questions or concerns the patient may have. Ensure the patient understands the importance of adhering to the follow-up care plan and monitor their understanding.
Coordinate discharge or transfer of patient
Arrange for the safe and appropriate discharge or transfer of the patient based on their condition and treatment plan. Consider factors such as transportation, medication needs, and any necessary referrals or arrangements. Collaborate with other healthcare providers and the patient's support system to ensure a smooth transition.
1
Discharge
2
Transfer
Document all procedures and findings in patient's records
Record all relevant information, procedures, findings, and interventions in the patient's records. Ensure accuracy, clarity, and proper documentation standards are followed. Use appropriate terminology and provide sufficient details for future reference and continuity of care.
Approval: Patient Records
Will be submitted for approval:
Document all procedures and findings in patient's records
