How to Make a Triage Report

Because there’s no time to waste, emergency room nurses write triage reports that assess a patient’s medical condition for doctors who must decide on the right treatment. Beginners follow a prescribed triage report format suggested by nursing schools or medical associations like the American College of Surgeons. While experienced nurses know instinctively what questions will elicit crucial medical information, they also are reluctant to deviate from standard triage procedure.

Instructions

• 1

  Start the report with a full identification of the patient. Provide the patient’s legal name, residence address, place of employment, phone number and date of birth. Record the date and time the patient entered the emergency room.

• 2

  Describe the patient's method of arrival. For example, did he patient walk in by himself or was he transported by a family member or ambulance squad?

• 3

  Specify the reason for the visit. State whether the patient was involved in an accident, was not feeling well or injured himself. Record the date of the accident or when the illness started if the patient waited more than 24 hours before seeking treatment.

• 4

  Write the patient’s chief medical complaints, commonly known as the “history of present illness.” Describe what the patient is feeling. For example, patients might feel back pain or dizziness.

• 5

  Provide a brief narrative of events for victims of accidents. For example, did passengers in a car report that the patient lost consciousness after the impact or did a patient report injuries but deny medical treatment at the scene.

• 6

  Describe the patient’s medical history. Note chronic conditions, such as asthma or diabetes. Provide descriptions and dates for prior surgeries the patient has had.

• 7

  Identify the patient’s current prescriptions. List other non-prescription medicine the patient takes routinely.

• 8

  Describe the patient’s appearance, mood and behavior. Note any unusual wardrobe choices. Specify whether the patient’s mood is upbeat or depressed. Point out whether the patient seems agitated or is compliant with emergency room staff.

• 9

  Narrate the patient’s course in the emergency room. For example, after describing his chief complaints to the triage nurse, was the patient transported to the x-ray room and then given a sedative.

• 10

  Summarize discharge instructions. For example, was the patient taught how to care for a wound or was he instructed to follow up with his regular doctor within two days of discharge. Identify medicine prescribed by stating the dosage and dose.