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Telephone Triage
Roles, Tools, and Rules

Online Continuing Education Course

Course Description

Continuing nursing education (CNE) course on tools and best practices common in telephone triage. 3 contact hour CE written by industry expert Sheila Wheeler includes assessment, documentation, and selecting the correct protocol.

Course Price: $24.00

Contact Hours: 3

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Telephone Triage
Roles, Tools, and Rules

COURSE OBJECTIVE:  The purpose of this course is to educate nurses about telephone triage nursing as an expanding subspecialty and provide an overview of tools, practices, and issues common in telephone triage practice.


Upon completion of this course, you will be able to:

  • Define telephone triage.
  • Describe the practice settings and primary populations that utilize telephone triage.
  • Summarize the qualifications and expert nursing functions of telephone triage nurses.
  • Discuss best practices and tools for telephone triage.
  • Summarize the essential aspects of good communication required for telephone triage.
  • Identify red flags, rules of thumb, red herrings, and common pitfalls in telephone triage.
  • Describe three mnemonic tools used in telephone triage for assessing patients or symptoms.
  • Discuss common risk management issues in telephone triage practice.


Telephone triage is a clinical subspecialty practiced by licensed medical professionals (most frequently nurses) that involves the safe, appropriate, and timely evaluation of patient symptoms via the phone by trained clinicians. Telephone triage services can be offered within a range of practice settings, including emergency departments, general practice, primary care, pediatric practices, and managed care environments. Nursing telephone triage has become an integral mode of delivering healthcare services, especially during off-hours, on a national and international level (Huibers et al., 2011).

Telephone triage is defined as “an interactive process between the nurse and client that occurs over the telephone and involves identifying the nature and urgency of client healthcare needs and determining the appropriate disposition” (Rutenberg & Greenberg, 2012). Telephone triage interactions may require assessment, patient education, and crisis intervention. The goal of telephone triage services is to direct the caller to the appropriate level of care or service in a safe and timely manner in combination with providing self-care advice and direction (Blank et al., 2012).

There are a variety of naming conventions for telephone triage services; some nurses refer to telephone triage as “telephone advice” and consider themselves advice nurses, while others use the words telepractice or telehealth. Telehealth, however, is an umbrella term that describes the delivery of healthcare services through electronic modes (Nagel et al., 2013). For the purposes of this course, telephone triage is considered to be the interaction between patient and nurse that takes place exclusively by telephone.

The Focus of Telephone Triage

Telephone triage is focused on the assessment and disposition of symptom-based calls rather than message taking. While message taking is a current practice in some settings, most state boards of nursing support using a professional nurse as a medical decision maker. The message-taking role is more appropriately relegated to unlicensed assistive personnel.

Telephone triage does not involve making diagnoses—nursing or medical—by phone. Telenurses do not diagnose but rather collect sufficient data related to the presenting problem and medical history, recognize and match symptom patterns to those in the protocol, and assign acuity. Telenurses provide for the safe, timely disposition of health-related problems. Telephone triage aids in directing the patient to the right level of care with the right provider in the right place at the right time (Blank et al., 2012).

Telephone triage services can improve continuity of care, avoid unnecessary visits to the emergency room, reduce patient anxiety, provide education and self-care, and increase patient satisfaction levels as well as reduce risks from medical complications. Patients value the care that they receive. In fact, one study showed that reassurance was more important than the relief of symptoms (Wheeler, 2009). Clearly, reassurance and thoughtful attention to patient concerns—whether medical, informational, or even administrative—often meet patients’ needs and provide high satisfaction.

Practice Settings

Currently, formal telephone triage is practiced in three major settings:

  • Managed care organizations
  • Primary care and specialty group practices (e.g., pediatrics, oncology, obstetrics)
  • Emergency departments (EDs) and crisis lines

Occasionally, telenurses encounter crisis-level calls, such as poison ingestions, domestic abuse, rape, cardiopulmonary resuscitation (CPR) coaching, or threatened suicide. However, in many communities, nonmedical personnel with specialized training operate crisis hotlines such as poison prevention, rape crisis, and suicide prevention, and customarily manage such calls. Likewise, 911 medical dispatchers perform high-level telephone triage and coach callers in first-aid treatment, CPR, and the Heimlich maneuver until paramedics arrive.


In the 1970s, HMOs recognized telephone triage as a separate subspecialty. From that period forward, protocols, training, and standards have typically kept pace with technological advances. When high standards are maintained, telephone triage within the managed care setting is a successful, highly appreciated, and integral part of the larger system. Today, most managed care organizations as well as Medicaid use nurse telephone triage services for their members, with the goal of decreasing emergency room visits and referring to the appropriate level of care and services (Rutenberg & Greenberg, 2012).

Telephone triage call volume within this setting can be extremely high, making the work stressful. Telenurses usually have electronic algorithms or decision-support tools and access to patient demographic information via an electronic medical record (EMR) on which to rely. Typically, demographic information includes previous medications, medical history, and dates of recent medical visits. The EMR software program creates a paper trail; enables managers to track and trend calls; and creates statistics on call volume, types of calls, and individual staff workflow and dispositions.

Generally, managed care call centers are larger and better organized than most small offices, group practices, and ED systems. In the managed-care setting, electronic protocols and algorithms are provided, as are formal training programs and standards.


Office and ED practices can vary widely in standards and protocol availability. Most medical offices and specialty practices first began their triage systems using paper protocols and pen-and-paper documentation. Training may have been on-the-job. However, as the practice has evolved, basic nursing competencies in telephone triage have been established, as well as standard triage algorithms to guide nurses as they investigate patient information and symptoms (Rutenberg & Greenberg, 2012).

Telephone triage services that are offered within a primary care office or specialty area are meant to enhance or supplement access to care and manage appointments. This may involve reviewing test results, assisting with general healthcare questions, and assessing patient symptoms to guide the patient to the appropriate level of care. Telephone triage nurses may also make follow-up calls to high-risk patients to assess changes or check the status of symptoms after an in-person visit with the care provider (e.g., patients with chronic asthma or diabetes).

Telephone triage within the ED setting may involve nurses who are trained within that setting to take calls in order to determine the severity of a caller’s needs using a series of algorithms. The telephone triage process may be similar to asking questions in person as part of an intake procedure, only in this case, the patient is calling in and physical assessment and observations are not possible. The ED telephone triage nurse directs the caller to the appropriate emergency services if needed or makes recommendations for follow-up based on the established triage protocols (Rutenberg & Greenberg, 2012).


Crisis lines are not generally seen as providing telephone triage nursing. Obvious examples of crisis intervention lines are poison prevention, suicide prevention, rape crisis, and 911. Emergency medical dispatchers (EMDs) are nonmedical personnel or paramedics who respond to 911 calls for ambulance, fire, or police. They assess by phone the need for emergency service and are responsible for dispatching medical rescue vehicles to victims. Most medical dispatchers are high school graduates, two thirds are female, and most have no previous medical training. EMDs often receive some training for responding to a range of commonly encountered crisis-level medical problems.

Who Are the Callers?

Over the last 30 years, researchers have identified predictable caller populations (e.g., by gender or age), call patterns and peak call periods, and common health complaints. Armed with this knowledge, staff in medical offices, managed care organizations, and emergency departments can prepare with specialized training, protocols, and staffing adequate to meet the need at predicted high-volume periods.


Not surprisingly, frequent callers are often from high-risk age groups: the very young, the frail elderly, and women of childbearing age. In internal medicine, women called twice as often as men. The percentage of calls made regarding children less than 4 years of age tends to be disproportionately large compared to the number of children in a given pediatric practice.


In family practice settings, peak calling time trends fall between 10 a.m. and noon, with the majority of calls occurring Monday through Friday. There is also a pattern of heavy call volume Monday mornings, Friday afternoons, during the lunch hour, and in the late afternoon. This may occur as patients become aware of their own symptoms after the demands of work are finished. When calling about their children, parents may notice that their children are not well when they are reunited with them after work.

In both the ED and office settings, there is a substantial volume of calls on weekends, holidays, and after hours when offices are closed and access to healthcare is limited. In a review of literature from the past decade, researchers discovered that half of all after-hours calls in a family practice occur on weekends (Huibers et al., 2011).


Not surprisingly, in the primary care setting a few complaints make up the bulk of calls. Most common are:

  • Upper respiratory infections (URIs)
  • Fever
  • Gastrointestinal (GI) problems
  • Viral infections
  • Minor trauma
  • Back pain
  • Anxiety
  • Otitis
  • Urinary infections

In pediatric practice settings, the majority of the calls are typically about respiratory problems, fever, GI problems, skin and infectious diseases, and trauma.

In the ED setting, the top presenting problem categories are GI, respiratory, OB/GYN, and trauma (O’Malley et al., 2012).

Who Performs Telephone Triage?

Telephone triage services are traditionally performed by specially trained, licensed registered nurses (RNs), but the role is at times performed by physicians or other trained medical personnel. Nurses working in telephone triage use their nursing assessment skills to a high degree; they also need excellent critical thinking and communication skills. Soliciting focused information and listening to the patient are key skills for timely assessments (Rutenberg & Greenberg, 2012).


Nurses working within the specialty of telephone triage are required to have a current license to practice as a registered nurse, along with the following recommended qualifications:


  • 10 years of clinical experience in a medical-surgical, pediatric, or other specialty unit
  • Emergency department triage experience preferred (walk-in or telephone)
  • High levels of experience or expertise in:
    • Crisis intervention
    • Teaching/coaching
    • Disease management
    • Diagnostic/monitoring


  • Good judgment and critical-thinking skills
  • Compassionate and caring manner with patients
    • Telephone “charisma”
    • Forms instant rapport
    • Customer service–oriented
    • Helpful, warm, open, and inviting
  • Excellent communication skills (written, verbal, and technical)
    • Articulate
    • Able to communicate well at fifth- to eighth-grade level
    • Bilingual language skills a plus
    • Concise, clear documentation skills
    • Excellent listening skills
    • Proven typing skills at 30 words per minute
    • Computer and software management
  • Excellent negotiation skills
  • Current basic life support (BLS) certification


  • Functions well in a high-stress environment and under time pressure
  • Tolerates ambiguity well
  • Works well independently
  • Possesses life experience as parent/caregiver
  • Works effectively with:
    • Culturally diverse populations
    • Educationally diverse and illiterate populations
    • Non-English-speaking populations
    • High-risk populations


Telephone triage programs are systems with integrated elements—staff, training, protocols, documentation forms, and standards—that work together to provide safe, timely delivery of care or access to care. Researchers have not yet determined which protocol system works best; however, it is safe to assume that protocols and decision-support tools grounded in the nursing process and related research, with built-in fail-safe systems, offer the best decision-making support for telenurses.

Along with incorporating training and algorithms, triage systems should offer the ability to record and audit calls for quality assurance and training opportunities. Patient confidentiality should be addressed by informing callers of this process.

Telenurse Functions

Telephone triage nurses function as a primary point of contact as patients call in with a variety of health or illness questions. The triage nursing role uses nursing assessment, intervention, and referral as primary therapeutic interactions. Nurses in this role must possess excellent communication, assessment, listening, and critical-thinking skills. Telephone triage nursing focuses on the following:

  • The helping function: In telephone triage, the key functions of the helping role are creating a healing relationship through 1) attending to (listening) or “presencing” (i.e., being present), 2) maximizing patients’ control, and 3) providing comfort and connection through the voice (rather than touch).
  • The diagnostic function: Strictly speaking, telephone triage is not intended to provide diagnoses. However, within limits, nurses can detect and document significant changes in the patient’s condition, perform pattern recognition and matching, anticipate problems, and formulate treatment strategies.
  • The crisis-intervention function: Nowhere else is the instant grasp of rapidly changing situations more vital than in crisis intervention by phone. Telenurses are often inadvertently cast in the role of first responder as they receive field calls regarding imminent births, trauma, suicide, and ingestions. (Not all communities have fully developed 911, suicide prevention, or rape crisis hotline systems.)
  • The monitoring function: Currently, most telenurses advise and may even monitor simple home treatment interventions and instruct patients in self-evaluation. In the future, the newly emerging area of disease management will likely make telemonitoring a standard function of telepractice. As technology and the field of telehealth continue to grow and expand, the trend toward telemonitoring will grow, allowing more patients to be treated at home.

Telehealth nursing delivers care in a nontraditional manner—with no physical connection between the nurse and the patient. Tuxbury (2013) studied the way in which both nurses and patients experience “presence” within their interaction during telehealth encounters. Presence is described as a special connection that benefits both nurse and patient. In this study, presence was reported as an authentic, therapeutic connection between the telenurse and the patient during their call or series of calls to address the patient’s health concern.

Telehealth interventions have resulted in positive results such as decreasing healthcare costs and increasing access to care. However, the use of telehealth has changed the pattern of nurse-patient proximity, which may alter the patient’s therapeutic experience of nursing presence.

Best Practices

Best practices are defined as the most efficient and effective ways of accomplishing a task while achieving the best results. Best practices are based on repeatable procedures that have proven themselves with large numbers of people over time. The concept of best practices derives from the belief that proper processes, checks, and testing can produce a desired result with fewer problems and unforeseen complications. Best practice is the assertion that there is a technique, method, process, or activity that is more effective at delivering a particular outcome.

In the world of telephone triage, best practice translates to employing the best human elements (staff), utilizing the best critical-thinking strategies and processes (nursing process), and using the best tools (standards-based protocols and forms). Thus, best practice depends on adequate numbers of experienced, qualified staff with solid communication skills, both written and spoken. (A sample score sheet can be used to assess a telenurse’s skills.)


To the degree that protocols are standards-based, they can reduce ever-present risks related to decision-making errors. Following are standards for telephone triage protocols based on those developed by the Institute of Medicine for decision-support systems (Wheeler, 2013):

  • Validity: If protocols are followed, it will lead to expected outcomes.
  • Reliability/reproducibility: Given the same data, other groups of nurses would produce the same results.
  • Clinical applicability: Protocols explicitly state the populations to which they apply.
  • Flexibility: There is a “user’s guide” with complete operating instructions, including underlying assumptions and exceptions to recommendations.
  • Clarity/user friendliness: Protocols are written in unambiguous language using precisely defined terms in an easy-to-follow mode of presentation.

Minimal best practices for protocols include an annual review and updates, comprehensive coverage of presenting problems, and integrated forms.

Teletriage and the Nursing Process

Generally speaking, telephone triage nurses utilize a slightly modified version of the standard nursing process (assessment, diagnosis, planning and intervention, and evaluation). Their diagnosis process consists of formulating a working diagnosis, or impression. Planning and intervention is based on the selected protocol’s disposition, and advice is provisional. Evaluation is carried out when the nurse provides patient teaching and self-evaluation techniques through follow-up instructions and feedback from the protocol.


Assessment is the most critical and substantive step of telephone triage, since pattern recognition is dependent upon the systematic collection of data. It is important for the triage nurse to start the assessment process with the documentation form rather than by selecting a specific protocol. The nurse may elicit and document information from the patient using one of the global telephone triage standard assessment tools such as the mnemonics SAVED, SCHOLAR, PAMPER, or activities of daily living (ADL), as appropriate. (For more on this, see “Assessment and Documentation” later in this course.)

Once the nurse has a general sense of the problem(s), a protocol is selected that best matches the patient’s presenting problem. When patients present with multiple symptoms, the protocol that has the highest likelihood of leading to a healthcare appointment should be utilized; this can be clarified by asking the patient which symptom is the most bothersome.


In telephone triage, the “diagnosis” step requires interpreting and analyzing patient data, identifying patient resources, and formulating a working diagnosis, or impression. Using the patient’s own words combined with the approved terminology and abbreviations, the nurse documents the impression. The following are examples:

  1. Abdominal pain, severe, sudden onset
  2. Ear trauma, severe pain
  3. Vaginal discharge, Hx. STI Exp.

Planning/intervention is determined after pattern recognition and matching. Patterns (symptom complexes) are classified according to the level of acuity, or disposition: emergent, urgent, acute, and nonacute levels. The nurse prevents, reduces, or resolves potential or identified problems by adhering to the protocol disposition and directives.

The treatment plan is composed of two parts: the disposition and the advice.

  • Disposition: Always advise the patient when and where to come for treatment. The site of care may vary depending on the hour and day of the call. After hours, the patient may need to be seen in the ED. Keep abreast of changes in clinic hours, which may be expanded to include evenings, weekends, and holidays.
  • Advice: Home treatment advice often includes information related to over-the-counter (OTC) medications and common self-care strategies.

In telephone triage, evaluations that would normally be performed by the nurse in face-to-face encounters must be carried out by the patient (guided by the nurse). Thus, “evaluation” is modified to become “patient self-evaluation instructions.” The nurse may also choose to monitor progress and self-care activities via follow-up calls to determine if home treatment is effective or if upgrading is needed. Review as appropriate any emergent, urgent, or acute symptoms for which the patient must continue to observe.

  • Follow-up instructions: In addition to the disposition and treatment plan, always include standard follow-up instructions and a disclaimer in the instructions to the caller.
  • Patient call-back: Always advise the caller to call back if the symptoms worsen or new symptoms arise.
  • Nurse follow-up calls: Routine follow-up calls should be made for children under 2 years of age and for abdominal pain, fever, diarrhea, or marked change in activities of daily living.

Protocols vs. Professional Judgment

Confusion often revolves around what ultimately determines the correct disposition—protocols or professionals? This issue continues to be debated. If the premise that protocols are the bottom line were true, then the nurse wouldn’t really matter. In fact, one expert maintains that information technology can potentially transform nurses from active decision makers into passive “system operators.” On the other hand, some experts suggest that protocols may actually interfere with critical thinking at times (Gladwell, 2005).

While established protocols are an important factor of the telephone triage system, the most critical component is the knowledge, experience, and critical thinking skills of a well-trained RN. Current standards of practice stress that RNs should perform decision making because protocols alone cannot guarantee safe practice.

Blank and colleagues (2012) conducted a review of research looking at the appropriateness of telephone triage decision and found that the majority of the (nurse-delivered) telephone triage decisions were appropriate (measured as accurate or adequate) and that the majority of callers complied with recommendations.


Are protocols decision-making or decision-support tools?

Some telephone triage designers favor protocols as decision-making tools, maintaining that nurses should use protocols based on strict algorithms. Others see the RN as the true decision maker, with the protocols serving as decision-support tools. Decision-making systems may allow unqualified operators to make decisions that are beyond their level of training and experience, whereas decision-support systems remind an experienced decision maker of information based on clinical knowledge that reinforces nursing judgment and best practices for decision making.

Decision-making tools are designed to be followed rigidly by answering yes or no to decision tree questions in order to reach a final disposition. This approach is based on black-and-white thinking, or “binary code,” which assumes that the information received is both accurate and sufficient in quantity and quality to determine a disposition. Such tools can break down in the “real world” of telephone triage.

Decision-support tools are based on pattern recognition, encouraging the RN to use critical-thinking skills, context, and pattern matching to determine a disposition. This approach mimics the way the brain solves problems by presenting the user with patterns to match with the patient’s presentation. The examples presented in this course are based on a decision-support approach.


All successful nursing care hinges on good communication. In telephone triage, the challenge is to push the limits of good communication to what is possible by developing a unique relationship with the patient. The manner of communication is as important as what is communicated. Nurses must inspire, negotiate, persuade, and engender trust. “Telecharisma” is a “magical” characteristic of telenurses. From their first words of greeting to the way they listen, respond, and ask questions, charismatic nurses working in the field of telephone triage demonstrate warmth, caring, and trustworthiness.

Successful communication requires a sender, a message, a mechanism, and a receiver. For the message to be complete, information usually has to flow in both directions. Experts have found that too little or too much information impairs critical thinking and diminishes the chances of the message being received and understood. With telephone triage, the prospect of too little information is increased due to lack of sensory input and information.

Thus, because the “signal” is weak, barriers that in person are not very formidable can become nearly insurmountable on the telephone. Messages may be impaired by lack of trust or by unexplored feelings, needs, and biases. Patients’ and nurses’ beliefs, attitudes, and perceptions of symptoms become obstacles in themselves. Ineffective communication may also lead to increased legal liability and substandard patient care.

In telephone triage practice, nurses can facilitate effective communication by closely attending to and receiving messages, clarifying or asking for detail, reflecting, and paraphrasing to check accuracy. At the bedside, speech, smell, touch, sight, and emotional cues paint a rich picture of the patient’s condition. On the phone, communications are limited to verbal and emotional cues. The risk of miscommunication is great. Although it is possible to gain limited tactile and visual information gathered by proxy from callers, nurses receive, analyze, solve problems, and instruct without observing the patient.

The sections below offer three best practices to enhance critical thinking: adequate time, open-ended questions, and speaking directly to the patient.

Allow Enough Time

Careful communications require adequate time. If callers perceive the nurse as “time driven,” offering few explanations, and making little attempt to build rapport, communication breakdowns increase. Some callers, dissatisfied with the brevity of the call and lack of emotional support, will fail to follow the nurse’s advice.

When it comes to “talk time” in telephone triage, there are no shortcuts. Adequate time enhances decision making and critical thinking. A landmark study compared performances of pediatric nurse practitioners with pediatricians (Perrin & Goodman, 1978). The authors discovered that pediatric nurse practitioners performed as well as or better than physicians in telephone triage. The nurse practitioners were judged to be warmer and more open to questions and left callers feeling more satisfied. They spent significantly more time per call than physicians (MDs, 3–5 minutes; RNs, 5–7 minutes). Perrin and Goodman consider that the additional minutes reflected an investment in patient education, not inefficiency. Current standards show that an average timeframe for a telephone consultation is 8–10 minutes or more, depending on the type of call and caller (Rutenberg & Greenberg, 2012).

Use Open-Ended Questions

Open-ended questions provide for better and more reliable data gathering by encouraging the patient to perform the work of describing symptoms. Asking leading questions—a flawed technique often related to being time-driven—simply elicits yes or no answers, thereby yielding faulty data. Resist using leading questions, which cloud the picture by providing the answer in the question. Such questions—“Is the pain severe?” “Are you having bloody stools?” “Are you having difficulty breathing?”—usually elicit yes or no answers. Open-ended questions—“How would you describe the pain?” “What are your stools like?” “What can you tell me about your breathing?”—eliminate yes or no responses. In telephone triage, most data collection should be gathered with open-ended questions (Rutenberg & Greenberg, 2012).

There are several exceptions to the policy of utilizing open-ended questioning. Exceptions include crisis-level calls and calls from children, frail elders, and poor historians. In such instances, use facilitative questions such as: “Is the pain better, worse, or the same as it was yesterday?” “Is the bleeding dark red or light red?” This is a compromise between open-ended and leading approaches that may still yield better data than leading questions.

With the crisis intervention call, where decisions must be made within seconds, leading questions are appropriate. Appropriate questions would be: “Is the victim conscious?” “Breathing?” When an immediate disposition is imperative, open-ended questions are too time-consuming.

Speak Directly with the Patient

Many pitfalls can be avoided by talking directly to the patient when possible, although with children under the age of 8 years, some older callers, or poor historians, this may not be feasible. Many calls are mistriaged by not making the extra effort to speak directly with the patient. This strategy will not only improve the quality of information collected and foster trust and compliance, but it can also expedite the call.


A wife placed a call to the nurse triage line for a primary care clinic stating that she thought her husband might have the flu because he had a high fever and was not responding to Tylenol. The nurse provided the patient an appointment that same day. The patient was seen and diagnosed with seasonal flu.

The wife called again the next day stating that the patient had a “pounding headache and stiff neck.” He was once again given an appointment in which the physical exam was unremarkable.

Day 3, the wife called again, stating that she was concerned about her husband because “his fever was still 102.9 °F and still not coming down with Tylenol.” When asked if her husband had a stiff neck, the wife stated “no” and offered no new information.

The nurse, sensing that perhaps the situation was more urgent (this being the third call from the patient’s wife for the same problem), asked to speak directly to the patient. When the nurse spoke with the patient and asked about symptoms of neck pain, the patient responded that he was continuing to have severe neck pain along with headache and fever. This direct assessment prompted the nurse to direct the patient to go urgently to the ED for a medical evaluation. The patient was evaluated in the ED and diagnosed with meningitis. Acute and swift treatment avoided any long-term neurological effects for the patient.


In this case, because the nurse spoke directly to the patient, a clearer picture of the clinical situation emerged. The nurse recognized the red flag of repeat phone calls for the same problem. This case was further complicated by the fact that the patient had also been evaluated by his primary care physician, and this may have given the nurse a false sense of security.

If the nurse had failed to speak directly to and assess the patient, the disposition may have simply been for monitoring and self-treatment of the patient’s assumed flu-like symptoms. The patient may have developed further symptoms, which could have resulted in a significant neurological event.


In telephone triage, decisions must be made under conditions of uncertainty and urgency. Uncertainty is due to partial or inaccurate information, and urgency is based on the fact that telephone triage is a high-stakes activity, with calls being processed in an average of 8–10 minutes. One of the pitfalls of telephone triage is time pressure. This time constraint may cause the nurse to use less information to make assessment and decisions, which may result in suboptimal outcomes (Rutenberg & Greenberg, 2012).

Decision making is made more complex by sensory deprivation, conflicting goals (such as call quotas vs. quality interactions), “noise” (irrelevant data, long-winded histories), and multitasking (thinking, listening/talking/questioning, reading, writing, synthesizing information, pattern recognition). The nurse must focus on what is most salient—the meaningful bits of information—and identify patterns to form reasonable working diagnoses.

Telephone triage nursing is considered a high-stress activity due to its fast pace and potential for crisis-level calls, both of which can interfere with critical thinking. The experienced triage nurse may need to make decisions when a patient scenario does not follow the standard protocol or decision-support tool algorithm. The decision-making approach has been studied and falls into three categories (Rutenberg & Greenberg, 2012):

  • Pattern-recognition decision making: Patients in this category are experiencing symptoms that are considered emergent and life threatening. The patient deposition is based primarily on symptoms. The decision is made quickly and based on the experience and intuition of the nurse. Examples of pattern-recognition decision making are calls related to problems with airway, breathing, circulation, or neurological deficit (ABCD) such as airway obstruction, hemorrhage, or shock. A patient may state, “I can’t catch my breath!,” which would be the pattern-recognition clue to the nurse to recommend that the patient be triaged directly to the emergency department via ambulance.
  • Focused decision making: Patients in this category are experiencing problems that are potentially life threatening. With this category, decisions will take a bit longer, with a focus on exploring the specific problem. The nurse makes a decision based on forming a hypothesis and ruling out problems. An example of this patient type is a woman who calls with abdominal pain of several hours. In this case, the information gathering is focused on the pain. With this example, the patient has a new symptom that is potentially urgent, which should cue the nurse to recommend a visit within 24 hours or sooner, depending on the severity and nature of the pain.
  • Deliberate decision making: Patients in this category are experiencing problems that are obscure or complicated and are considered non–life threatening. In this case, the nurse will take time to explore the entire picture to be able to understand the nature of the problem. An example is a patient who calls in with a rash that developed three days ago and has not resolved. This may be a scenario when the nurse would recommend self-care or home treatment until an appointment can be arranged to evaluate the problem.

Mental skills are at the core of telephone practice and require a supportive environment. Working short staffed in a high-volume, noisy environment and without protocols, training, or documentation will only heighten stress and uncertainty, thereby diminishing mental skills. On the other hand, a quiet, moderate call-volume environment with adequate numbers of qualified, experienced, and trained staff who are equipped with guidelines or protocols and documentation forms reduces uncertainty and supports mental clarity.

Human beings tolerate ambiguity differently. Thus, managers may use psychological testing to screen prospective staff for tolerance of ambiguity, selecting the best and most stress-resilient decision makers.


Critical-thinking skills and a systematic approach can remedy many potential pitfalls. The phrase layers of safety in relation to telephone triage practice includes the following practices:

  • Identify what is salient and ignore what is not.
  • Apply rules of thumb to make rapid decisions.
  • Utilize “red flags” to rapidly identify high-risk problems or populations.
  • Employ consistent, comprehensive data-collection strategies.
  • Use the nursing process, modified for telephone triage.
  • Use a documentation form with the nursing process embedded.
  • Use protocols that support the nursing process.

Additional layers of protection or risk management approaches might include:

  • Taking continuing education courses
  • Understanding the Nurse Practice Act
  • Obtaining written copies of the telephone triage job description, qualifications, policies, and procedures

The Role of Intuition

Researchers have paid a lot of attention to the role of intuition in decision making. They maintain that intuition can be developed and offer a variety of suggestions. Klein (2003) advises learning to detect problems through emotional cues—a “gut feeling” when something isn’t right. He recommends developing an active stance, so that if something doesn’t make sense, it acts as an alarm that is not to be dismissed. He also suggests becoming conscious of organizational barriers such as rigid procedures or institutionalized inertia. Finally, he suggests reframing the situation and consulting with colleagues to review with fresh eyes.

Gladwell (2005) states that good decision making relies on a balance of conscious and instinctive thinking. Reducing complex problems to their simplest elements aids in decision making. He warns that too much information can paralyze the unconscious. In other words, remember to keep it simple.

Alfaro-Le Fevre (2006) recommends improving critical-thinking skills by avoiding behaviors such as stereotyping others, resisting change, and seeking conformity. In addition, she suggests reducing barriers to intuition: anxiety, stress, fatigue, lack of time, feeling judged, and environmental distractions.

Rules of Thumb

A rule of thumb is a way of proceeding based on experience and sound judgment. Rules of thumb provide practical methods that can generally be relied upon for an acceptable result. Klein, an expert in medical decision making, studied groups of ICU nurses, firefighters, and others who make decisions under pressure (2003). He discovered that these experts don’t logically and systematically compare all available options. In real life, that methodology is too slow. Instead, they quickly size up situations and act, drawing on experience and intuition. Rules of thumb often underlie their expertise and intuition.

The following rules of thumb represent experts’ collective “pearls of wisdom” in telephone triage. They are a body of knowledge that every telenurse should commit to memory. Through study and integration of these rules, novice practitioners can improve their decision-making proficiency and efficiency. These suggestions are not an exhaustive list; telenurses can add their own “rules” as appropriate.

  • Always err on the side of caution.
  • When in doubt, send ’em out.
  • Beware the middle-of-the-night call.
  • Be alert to possible atypical, silent, or novel presentation.
  • Serious symptoms may present as a single symptom or a complex of symptoms.
  • Always speak directly with the patient when possible.
  • Assume the worst until proven differently.
  • Make corrections for your own fallibility.
  • The more vague the symptoms, the greater the need for good data collection.
  • Speed does not equal competence; avoid premature closure.
  • Never abandon the caller in crisis.
  • Temperature extremes often trigger medical problems.
  • All severe pain should be seen urgently.
  • Several calls in a short period of time may be an indicator of acuity.
  • Beware the developing disease.

An experienced pediatric nurse received a call at 10 p.m. from a mother of a two-year-old male child who had a temperature of 101 °F orally with a “cold and cough” and was “breathing funny at times.” The mother denied nasal flaring, retractions, cyanosis, or other symptoms of concern and stated that her child was acting fairly normal, but she was most worried about the “funny breathing.” When the nurse asked to listen to the patient breathe, she was concerned about the raspy character of the respirations. “Erring on the side of caution,” she told the mother to take her child to the ED. In the ED, the child was diagnosed with pneumonia, for which he was hospitalized for treatment and made a full recovery.


Age is a major feature in many rules of thumb. For instance, extremes of age can markedly affect the immune response as well as the ability to regulate body temperature, as illustrated by these two key rules of thumb:

  • The older (younger) the patient, the greater the risk of hypo- or hyperthermia.
  • Assess all sick children and older adults for dehydration or sepsis.
Infants and Children
  • Kids get sicker quicker.
  • To avoid night calls, visits, and crises, schedule day appointments.
  • Neonates are at increased risk for overwhelming infection due to prematurity, traumatic delivery, maternal illness, or neonatal stress.
  • Confusion in children is always considered emergent.
  • Always err on the side of caution with children, especially with infants and toddlers.
  • Pediatric populations are at greater risk for hypothermia and hyperthermia.
  • For children under 4 years, symptoms tend to be very generalized; for those over 4 years, symptoms tend to be more specific.
  • Infants under 3 months of age with fever of 38 °C (100.4 °F) should be seen immediately.
  • All parents have the potential to abuse their children physically at some time.
  • Assume any symptom of STDs (discharge, lesions) in a child to be sexual abuse until proven otherwise.
  • Always elicit an immunization history; lack of, or inadequate, immunizations place a child at risk.
  • Assess all children with unexplained symptoms for possible unintentional or purposeful ingestion/exposure to toxins, inhalants, and street or prescription drugs.
  • Any teenager who is depressed is at risk for suicide.
    (Rutenberg & Greenberg, 2012)

Teenagers are especially vulnerable to depression and suicide due to several factors: easy access to alcohol and drugs, increased sexual activity, complex societal demands, negative role models, and increased family disruption. The precipitating factor may be:

  • Loss or betrayal of trust
  • Romantic break-up
  • Failure in school or sports
  • Move to a new neighborhood
  • Peer pressures
  • Conflict regarding dependence and independence
  • Poverty
  • Unwanted pregnancy
  • Sexual problems, rape, incest, sexual dysfunction
  • Gender-identity problems
  • Peer- or media-emphasized suicide
  • Treatment for mental illness
  • Legal problems
    (Rutenberg & Greenberg, 2012)
Older Adults
  • Symptoms in older adults may be atypical, silent, or late (e.g., the patient may merely present with fatigue as a symptom of pneumonia or infection).
  • All sudden confusion in older adults is considered emergent.
  • The hydration status of all older adults is a critical assessment point.
  • Older adults are at risk for adverse drug reactions (ADRs). The greater the number of drugs, the greater the incidence of ADRs. Moreover, as the number of daily doses increases, compliance may decrease.
  • All older adults with unexplained symptoms for ADRs, “chemical restraints,” or possible ingestion (intentional or accidental) should be carefully assessed. Exposures may be due to toxins, alcohol, or overmedication with prescription or OTC medications.
  • Older adults may be poor or forgetful historians. Err on the side of caution.
  • Elderly white, retired widowers are at highest risk for completed suicide.
    (Rutenberg & Greenberg, 2012)

Symptom-based rules of thumb include the following:

  • Once an ectopic pregnancy, always an ectopic pregnancy.
  • Any bleeding in pregnancy is considered an ectopic until proven otherwise.
  • All severe pain must be seen within 8 hours or less.
  • Beware of any pain that awakens the patient or prevents sleep at night.
  • Epigastric pain in males >35 and females >45 is considered a myocardial infarction (MI) until proven otherwise.
  • Any pain between the navel and the nose is chest pain until proven differently.
  • All first-time seizures must be seen.
  • All rashes are contagious until proven otherwise.
    (Rutenberg & Greenberg, 2012)

Trauma-based rules of thumb include the following:

  • Never remove impaled objects.
  • Always check for head injury with face or jaw trauma.
  • All breaks in skin made by human teeth are presumed to be a human bite.
  • All snakes are considered poisonous until proven otherwise.
  • All chemical and electrical burns are potentially worse than they appear initially.
  • Always be alert to unwitnessed accidents and to mechanism of injury (major trauma, motor vehicle accidents, falls >15 feet, blunt trauma).
  • Always review a caregiver’s assessment of trauma. They may focus on a minor problem that is more visible (avulsed tooth) and miss a more serious one (head injury).
  • Trauma with a suspicious history should be considered possible abuse.
    (Rutenberg & Greenberg, 2012)

The “eight Es” of MI include the following:

  1. Extreme emotion
  2. Extreme exertion
  3. Extreme weather (heat wave/cold snaps)
  4. Extreme eating
  5. Extreme age (over 75 years)
  6. Extreme epigastric distress
  7. Essential hypertension
  8. Early morning

A woman calling into the nurse triage center gave her chief complaint as a “cold.” Unknown at first to the nurse, the patient was actually concerned about her shortness of breath and chest tightness, but she didn’t mention it because she was hoping those symptoms were related to her cold.

As the nurse assessed her and took her history, the patient reported watery eyes, runny nose, nausea, and a cough. The nurse investigated further, and the patient admitted to having shortness of breath and chest tightness. The patient was referred to the ED and diagnosed with an acute MI.


The fact that the triage nurse conducted a good assessment and explored the patient’s symptoms thoroughly made all the difference in this case. The nurse also followed the symptom-based rule of thumb for MI and chest pain.

“Red Herrings”

A major task in decision making is to determine which data are relevant and which are not. Data must be collected, considered, weighed, and even ignored in order to perform pattern recognition and arrive at a proper disposition. For example, key pieces of contextual information—age, gender, and previous medical history—are always salient; key symptoms may be salient; and other more general and nonspecific symptoms may be given less weight.

There will also be information that is irrelevant and must at times be consciously ignored in order to come to safe decisions. Such data might be called “red herrings”; they are distractors and divert the nurse from more significant data. Red herrings may cause the nurse to jump to making conclusions, drawing stereotypes, or ending the call prematurely. For example, if a patient who is immediately post-operative calls in with symptoms of nausea and vomiting, the triage nurse may prematurely conclude that the symptoms are due to effects of anesthesia and not explore or assess the patient further.

Red herrings can originate with the patient or the nurse. The patient may deny or misinterpret symptoms or might miscommunicate. The nurse may misinterpret symptoms or patient history. For example, a patient who was “seen recently in the ED” may now be experiencing new, unrelated symptoms, which the nurse must evaluate. A patient who is “on an antibiotic” should not lull the nurse into complacency; methicillin-resistant staphylococcus aureus (commonly known as MRSA) may be the culprit.

One useful rule for avoiding red herrings is to “beware the developing disease.” Do not be misled by initial presentations that seem nonacute. What starts out as vague abdominal pain with low-grade fever may quickly develop into the classic picture of appendicitis. Follow-up calls should be mandatory for possible developing diseases, and especially for abdominal pain, respiratory problems, diarrhea, nausea and vomiting, fever, or marked change in activities of daily living (ADLs).

Common Pitfalls

For decades, researchers have repeatedly identified common pitfalls in telephone triage practice. The most common of these pitfalls include:

  • Stereotyping of patients and problems
  • Second guessing or over-reliance on callers
  • Improper use of or failure to use protocols
  • Inadequate talk time
  • Insufficient history taking and documentation
  • Premature closure

Stereotyping of callers can be avoided by obtaining the age, gender, and medical history. It is easy to mistake the caller’s gender or age from the voice. Nurses can also avoid stereotyping symptom patterns by careful and sensitive assessment of the problem and patient history and by taking care not to jump to conclusions. For example, burning on urination in an older female cannot simply be dismissed as a urinary tract infection; it may be symptomatic of a sexually transmitted disease. By the same token, the nurse who assesses a teenage girl who complains of abdominal pain without exploring the prospect of sexual activity, unprotected sex, and possible pregnancy runs the risk of potential delay in care.


Second guessing is often referred to as the “you’re not sick until I say you are” syndrome. To avoid making erroneous assumptions, telenurses resist either being dismissive of the caller’s concerns or over-investing in the caller’s assessment. Callers who claim that the problem is an emergency may have correctly assessed the situation, and telenurses should take them seriously.

On the other hand, the caller who has self-diagnosed a problem may lull the nurse into a false sense of security due to over-reliance on the caller. For example, the caller who begins by saying, “My new medication makes me feel dizzy” or “I was carrying some logs and now my shoulder really hurts” or “I have the flu,” may have seriously misrepresented the problem. This initial patient description must be set aside while the nurse elicits more details. Don’t assume that such symptoms are a result of a medication, musculoskeletal injury, or the flu, respectively. These complaints could be related to conditions like stroke, myocardial infarction, or sepsis, for example.


Even though protocols may be well designed and comprehensive, there are several ways in which the nurse can misuse them, including: 1) failing to use the protocol, 2) using the wrong protocol, or 3) using the protocol improperly. Failure to use protocols is obviously risky, but easily occurs when the nurse finds that no protocol seems to apply to the presenting problem. This is commonly referred to as the “out of protocol” experience.

Failing to collect enough information can lead to selecting the wrong protocol. Selecting the wrong protocol may lead to an inaccurate referral and/or disposition for the patient. Nurses may choose the correct protocol but fail to follow it correctly by choosing the wrong disposition. This can be remedied through providing comprehensive user’s guide instructions and protocol competency training (Rutenberg & Greenberg, 2012).

Telephone triage managers should also be aware of the pitfall of relying on protocols to take the place of formal instruction. Over-reliance on the protocol tool can lead to errors in triage. Training for critical thinking in history taking, communications, assessment, and decision making is key to safe practice. Potential problems can be averted through instruction in the correct and safe operation of the protocols and documentation form. Such instruction also prevents “protocol bias,” which develops when RNs who have been using one type of protocol must begin using a new one.

Electronic protocols and computers are—and always will be—essential to telephone triage as the mainstays for tracking, reporting, and trending. However, if electronic protocols are given too significant a role, nurses may become passive. What is required is a balance between nursing judgment and protocol.


The telephone triage process should begin with a rapid prioritization to determine callers who urgently need appointments. Expert nurses quickly build the clinical scenario through gathering key chunks of information: the patient’s age, gender, chief complaint, literacy or language level, emotional state (determined via the words, tone, pacing of voice), and previous medical history. This key contextual information can quickly identify high-risk patients or problems. This process, while appearing superficial, yields valuable information and often takes as little as 60 seconds. Alternatively, problems can arise when a protocol design fails to offer options for rapid prioritizing.

Some problems require more thorough questioning; the triage nurse needs to recognize when to pursue data collection to a greater degree. Whereas in the case of chest pain, the nurse may quickly elicit the key chunks of information (age, gender, symptoms) and make a decision, in a case such as vague abdominal pain, the nurse may spend more time gathering larger quantities of detailed information.

While performing a global assessment, the triage nurse needs to quickly recognize and assess any emergent situations that require aborting the formal protocol assessment process and direct the caller to the emergency department; however, in most cases, calls require a brief problem statement and patient history prior to deciding on a standard protocol and disposition.


To prevent errors, tools must meet standards for reliability. In telephone triage, the entire system (protocols, forms, training, and standards) is structured to reduce the prospect of failure, regardless of environmental factors. For example, the protocol and documentation form are integrated and include built-in fail-safe requirements that follow the nursing process steps and force users to collect adequate amounts of key information (age, allergies, previous medical history and medications, problem, patient history, etc.). This assists users within the practice of telephone triage to meet clear-cut standards (Rutenberg & Greenberg, 2012).

Documentation and Charting Essentials

The history-taking process begins by verifying the patient’s contact information (address and phone number). The nurse should remind the patient that this information is important in case the call is disconnected (especially since many patients’ only or primary phone is a cellphone, which can disconnect at a critical moment). Next, a brief health history is collected (chronic illness, current daily medications, and drug allergies), followed by a discussion of the patient’s current problem and primary reason for calling. Obtaining a brief health history as a first step creates context and gives an immediate sense of patient risk.

Information can be collected in any order that seems appropriate to the patient and the situation. It is not necessary to let the standard data collection form dictate the order of collection. In real-world situations, people volunteer information initially. The important point is to find a balance between listening to what may be a patient’s long-winded explanation and communicating the need to gather information in a timely fashion. Data is recorded into the appropriate field as the patient volunteers information; any information gaps can be filled with follow-up questions from the protocol.

Patients often present symptoms in erratic and disorganized ways. They may focus on one symptom to the exclusion of other, more important ones. An example might be the parent who is concerned about a child losing a tooth due to trauma, when the more serious problem is possible head injury. A critical step in data collection is to avoid being caught up in the patient’s perception and start the triage process with assessment questions and the documentation form. The rationale is to quickly sketch an outline of the problem. The next step is to fill in the details using a specific protocol.

It is also important not to select a protocol too quickly. Confining the interaction for the “first pass” reduces the risk of jumping to conclusions. As uncomfortable as uncertainty may be, choosing a protocol prematurely may lead the nurse down the wrong path.


Charting must be concise but complete, including accurate, timely observations in the patient’s own words, always using approved abbreviations and terminology.

  1. Quantify where possible; avoid vague expressions.
  2. Use time frames (8, 16, 24, 48 hours) as related to symptom duration or treatment plan.
  3. Form a “provisional, working diagnosis” or “impression.”
  4. Document advice per protocol name or number.
  5. Document protocol deviations/overrides/modifications.

A sample documentation form (Wheeler, 2009) is based on the concept of charting by inclusion. Charting by inclusion requires that the RN chart normal negatives (pertinent negatives) as well as abnormal findings. Pertinent negatives are “findings that are normal and significant” (e.g., no black or bloody stools). If you are charting by inclusion, pertinent negatives should always be written. In telephone triage, the issue of charting by inclusion or exclusion is best addressed by in-house legal counsel and written policies.

SAVED: Red Flags and High-Risk Patients

Research has identified several broad categories of high-risk patients and symptoms. These groups are signified by the acronym SAVED. These five categories are also known as “red flags.” Red flags help all practitioners to function more effectively. When red flags are raised, nurses are encouraged to use their intuition.


Severe pain (9 on scale of 10), severe bleeding (spurting, bright red), or severe trauma (falls from a height over 15 feet) are all conditions that the average layperson could identify as urgent. Strange symptoms include ill-structured, vague, atypical, or unusual presentations—symptoms that only astute professionals might recognize as urgent. Sudden, unexpected, or new symptoms; recurrent symptoms; or a marked change in the patient’s condition all qualify as suspicious or strange.

The “big six”—head, abdomen, chest, respiratory, dizziness, and flu symptoms—are also considered suspicious. These symptoms always require thorough investigation, primarily because they are often linked to underdiagnosed but potentially serious conditions such as ectopic pregnancy, myocardial infarction, or appendicitis.

Suspicious symptoms also apply to situations where the nurse has a “gut feeling” or a hunch about a problem. In such situations, if the nurse is uncomfortable with the protocol disposition, it is important to upgrade a problem or bring the patient in sooner.


Age is one of the most important pieces of data obtained. The very young, very old, and women of childbearing age are always considered high-risk patients. Due to immature immune systems, premature infants and those under 3 months of age are at highest risk. The “frail elderly” (anyone over 75 years of age or suffering from multiple or chronic diseases, functional disability, or psychosocial problems) are vulnerable due to failing immune responses. The childbearing years—always a high-risk period associated with pregnancy, birth control, and STIs—now extends from age 11 into the 60s.


Veracity refers to the ability to repeat the facts of the situation accurately without communication barriers. Obstacles to communication include: second-party calls, low-literacy callers, language barriers, extremely young or very inexperienced mothers, or caregivers unfamiliar with the patient.


Nurses can pick up many cues through careful attention to the words, tone, and pacing of the caller’s voice. There may be hysteria or denial, inappropriate affect in the caretaker or parent, or a history of psychiatric problems or substance abuse. Anxiety is always a red flag. Frequent calls in a short period of time can be an indicator of both caller anxiety and problem acuity.


Generally, debilitation refers to chronic illness. Chronic illnesses may include (but are not limited to) cancer, diabetes, heart disease, hypertension, mental disorders, asthma, or COPD. For the immunocompromised, debilitation may involve lack of adequate immunizations, chemotherapy, HIV, splenectomy, steroid therapy, transplants, or nephrotic syndrome.

Distance can often pose a problem in gaining timely access to care. For example, a patient/caregiver may be calling from a remote location several hours from a hospital, or the patient is reliant on public transportation to travel. In urgent situations, if timely arrival is difficult due to the lack of a car, the nurse must upgrade the disposition.

To summarize, quickly prioritize by using the high-risk categories within SAVED on the documentation form. Ask questions in any order, or simply let the caller tell their story at first. Use open-ended questions where possible.

S Severe/strange/suspicious symptoms
  • Severe pain, bleeding, trauma, diarrhea, vomiting, etc.
  • In children or elders, severe diarrhea, dehydration, infection symptoms
A Age
  • Premature infants and those under 3 months of age
  • All women of childbearing age
  • Sexually active adolescents (male or female)
  • All frail elderly
  • Men over age 35
  • Women over age 45
V Veracity
  • Second-party calls
  • Low literacy
  • Language barrier
  • With elders, suspected substance abuse; incoherent or slurred speech in patient caretaker; caretaker unfamiliar with patient
E Emotional status
  • Hysteria or denial; inappropriate affect in caretaker
  • Parent or caretaker with history of abuse (physical or sexual), psychiatric problems, or substance abuse
D Debilitation and distance
  • Chronic illnesses
  • Parent/caretaker calling from remote location over one hour from hospital
  • In emergent situation, patient unable to reach care within one hour due to traffic or lack of available car; reliance on public transportation that is sporadic or nonexistent at certain hours

Documenting high-risk patients and symptoms using SAVED can “defend” dispositions. For example, statements such as “abdominal pain, previous Hx ectopic pregnancy” or “nosebleed, severe, unresponsive to home Tx x 30 min” provide information that identifies a problem’s severity and that it was due to a previous medical history or a failure to respond to home treatment, respectively.

SCHOLAR and PAMPER: Problem and Patient Histories

Researchers have consistently pointed out the need to collect essential information related to the problem and patient history. The acronym SCHOLAR outlines key questions to elicit data on the problem history, and the acronym PAMPER elicits key information about the patient history. These mnemonics can easily be built into documentation forms as both prompts and question/answer tools to support nurses. While other well-known nursing mnemonics such as PQRST or SOAP may work well for face-to-face assessment, more detail is needed in telephone triage interactions.

S Symptoms and associated symptoms
  • Is it an isolated symptom or complex of symptoms?
  • Course of symptoms: Is it better? Worse? The same?
C Characteristics
(aids in precise description)
  • Quantitative (scale from 1–10)
  • Qualitative (sharp, dull, pounding)
H History of complaint
  • In the past, what was done? By whom? When? What were the results?
O Onset of symptoms
  • When did they start? How long have they been present?
  • Was the onset sudden or gradual? (Sudden = higher acuity)
L Location of symptoms
(strive for precision, e.g., RUQ, LLQ, etc.)
  • Localized? (higher acuity)
  • Generalized? (lower acuity)
  • Radiation?
A Aggravating factors
  • What activity, foods, position, etc., make it worse?
R Relieving factors
  • What activity, foods, position, etc., make it better?
P Pregnancy/breastfeeding For all women between 12–50 years of age, was there unprotected intercourse?
A Allergies Exposure to foods, chemicals, drugs, insect bites, cosmetics?
M Medications Daily over-the-counter, prescription, and birth control? As appropriate, recreational drugs, alcohol?
P Previous chronic illness Recurrent illness, multiple surgeries, family history?
E Emotional state Psychiatric history, current reaction to illness?
R Recent injury, illness, ingestions Recent accident or child/elder/spouse abuse/neglect? Exposure to communicable disease? Possible covert/unwitnessed ingestion?

Assessing Children, the Elderly, and Poor Historians

With children, some elders, and poor historians, it is difficult to get adequate information for two reasons: 1) the patient is preverbal or a poor historian, and/or 2) the patient has vague or ill-structured symptoms. In these cases, SCHOLAR and PAMPER may be unworkable. Instead, assess activities of daily living (ADLs) to elicit and compare the patient’s current state with their baseline state. With children and elders, baseline indicators of current health or illness provide the clearest picture when symptoms are vague, ill-structured, or absent (Rutenberg & Greenberg, 2012).

Since toxicity and dehydration are common risks with children, gather this information and then compare it to the descriptors in protocols for “Toxicity and Dehydration Assessment.” Marked changes in any of these indicators can be a sign of severe illness.

Breast/bottle/food # oz./cups/glasses per 24/16/8 hours
Emesis/diarrhea/urine # diapers/episodes per 24/16/8 hours
C Color Lips/skin/nailbeds
R Respirations Rapid/slow/labored
A Activity Work/play/daily routine
S Skin turgor Dry lips/tongue/tenting/sunken or bulging fontanel
S Sleep pattern Too much or too little
D Difficult to awaken or to keep awake
E Expression decreased
M Movement little to none spontaneous
E Eye contact/focus decreased
R Recognition of caregiver/parent decreased
I Interactivity decreased
T Talking/babble decreased


Once the triage nurse has elicited key information utilizing the documentation form and assessment tools, a provisional or working diagnosis, also called an “impression,” can be formed. The patient’s chief complaint in his or her own words (headache, nosebleed, vaginal bleeding) can be used to describe the problem, then modifiers or qualifiers are added to designate the level of acuity. For example, using a pain scale of 1–10, the nurse might document as follows: “abdominal pain, 9/10, sudden onset”; “ankle pain, 4/10, trauma history.”

The next step is to choose a protocol. In some cases, the triage nurse will use the generic protocol, a core protocol that serves as “infrastructure” for all other protocols. Protocol selection is based on the principle of prioritizing. The protocol is chosen based on information that matches the most serious-sounding symptom or one which most likely will lead to an appointment.

Patients rarely present with the classic picture of any disease. Patients’ disease presentations vary due to immune response, medical history, age, and the timing of the call in relation to the disease process. Thus, telenurses must carefully navigate the multitude of possible presentations. A myocardial infarction may present as one key symptom (like chest pain), a few generalized symptoms (nausea, vomiting, sweating), or the full-blown classic picture (crushing chest pain accompanied by shortness of breath, nausea, vomiting, dizziness, sweating, anxiety). It is the role of the triage nurse to determine what constitutes a match.

A Generic Protocol

Most providers maintain numerous protocols from which to choose. However, because each patient presentation and individual situation is unique, protocols may not cover every condition. This leads to what is commonly known as the “out-of-protocol experience”; it is remedied by the generic protocol (or fallback protocol), which can act as a safety net.

A generic protocol (Wheeler, 2009) is especially useful in three instances:

  • When the nurse does not know which protocol to use
  • When no other protocol quite fits the situation
  • When responding to calls about infants, elders, or poor historians whose presenting symptoms are vague or ill-structured

The generic protocol might also be used as a training device for novice practitioners.

Sepsis and Dehydration Protocols

With dehydration, the nurse should elicit and be alert to the context and combined effect of conditions that can worsen dehydration. These include extreme heat or humidity, exercise, fever, nausea and vomiting, diarrhea, low or no fluid intake, as well as age, chronic disease, degree and duration of fever, patient medical history, depressed thirst response, and medications.

Four-Tier Triage

The limits of telephone triage allow for three or four typical triage disposition categories. These include the following:

  • Emergent
  • Urgent
  • Acute
  • Nonacute
    (Rutenberg & Greenberg, 2012)

Each category refers to a flexible timeframe within which the triage nurse determines what is safe, prudent, and reasonable. Thus, the nurse has the professional responsibility to use his or her best professional judgment.

  1. Emergent-level calls. Generally speaking, these calls require paramedic transport. They involve severe, life-threatening symptoms. Patients must be kept NPO (nothing by mouth). Whenever possible, the triage nurse should remain on the line with the patient or implement a three-way conference call as appropriate with services such as suicide prevention, 911, poison control, or rape crisis. When a caller is advised to go to the ED or to labor and delivery, the nurse should call and notify the department of the impending patient arrival.
  2. Urgent-level calls. Urgent-level callers should be seen within 1–8 hours. However, some urgent symptoms may need to be seen as soon as possible at the most appropriate site. These patients must be kept NPO and will require paramedic transport if there is no readily available car or if the driver (caregiver/parent) is alone and/or too anxious to drive.
  3. Acute-level calls. In this model, acute-level calls are seen within 8–24 hours or given a next-day appointment.
  4. Nonacute-level calls. Generally speaking, nonacute-level callers are directed to come in as appropriate. Nonacute symptoms usually can be managed with telephone advice for self-care and/or an appointment.

When in Doubt

“When in doubt, always err on the side of caution” is a cardinal rule in telephone triage. Triage nurses must rely on their best professional judgment and use every means at their disposal to ensure that patients are treated in a timely manner. Time frames designated on the template are intended as a general guide. If a nurse has doubts about the severity of symptoms and condition, safety dictates the patient come in sooner rather than later.

Triage nurses may upgrade dispositions as appropriate (from urgent to emergent, nonacute to acute). However, nurses must never downgrade (urgent to nonacute) without a physician consultation. If the patient is noncompliant, the nurse should seek advice from the physician advisor.


The triage nurse should end each call with the final question “Is anything else worrying you?” or “Do you have any additional questions?” This step may reveal that a patient has an entirely different motivation and may even open the door to a new triage process.

Documenting a closing statement helps ensure that the patient has given informed consent. In other words, they comprehend the provisional diagnosis and proposed treatment, with the following understanding:

  • This is an impression, not a medical diagnosis.
  • The advice or home treatment is based on the impression.
  • If a patient disagrees with the impression, they may have an appointment.
  • If symptoms worsen or fail to respond to the home treatment, the patient agrees to call back or come in.
  • The patient agrees to the plan.

A key element to documentation is to elicit and document what the patient plans to do at the end of the call. This will demonstrate that there was agreement to a certain plan of action. Further, it ensures that the patient understands what to do and under what conditions he or she may need to ask for further help. The chain of command may also be used; nurses should not be afraid to go to the next higher level.


In the current managed-care environment, which seeks to contain costs by reducing inappropriate ED (with paramedic transport) and office visits, telenurses are sometimes forced to act as gatekeepers. As a result, nurses may unwittingly be caught in a bureaucratic trap. Triage nurses are required to balance practice guidelines and rules with their critical thinking and assessment skills. An experienced triage nurse many times has autonomy to act based on clinical experience and nursing knowledge. Nurses in the practice of telephone triage also need to consider and navigate through common risk management issues with their patients.

Delay and Denial of Care

With the nurse or the physician, two specific risk management issues—delay and denial of care—can haunt every decision made. That is because triage nurses provide access to appointments and referral to the ED. Delay or denial of care due to insurance coverage and practice network location are common situations that a telephone triage nurse may encounter in practice. Delay or denial of care can result in harm to the patient.


At 3 a.m. a mother called a pediatric specialty practice nurse triage line regarding her infant, who had a fever of 103 °F. The nurse failed to obtain a complete history and gave routine advice for fever control. She had consulted with the pediatrician on call but failed to provide a complete picture of the infant’s illness. On the orders of the pediatrician (who was acting on the nurse’s incomplete information), the nurse directed the parents to an ED that was in network for their insurance coverage about 45 minutes away. (The nearest ED was about 15 minutes away.) En route, the child experienced a cardiac arrest due to hypoperfusion syndrome and meningitis. Because of impaired circulation, the child’s hands and feet had to be amputated.


In this case, the triage nurse may have directed the mother to bring her infant to the nearest ED if more complete information had been obtained, thus prompting an emergency exception from the rules for in-network services and avoiding a delay in care.

Payment Concerns

Patients themselves may contribute to delays through their own reluctance to call 911. Charges for emergency services, including ambulance transportation, may be barriers to their making the call for 911 services.

The telenurse’s priority is to ensure patients’ timely access to emergency services rather than considering who will pay for paramedics. The nurse should always be alert to the possibility of patients’ concerns with payment issues. This “hidden agenda” may lead the caller to minimize disclosure of symptoms in order to avoid incurring the costs associated with paramedic transport. Detailed written policies and procedures should clearly address the access issue and the correct procedure to follow.


A male patient who was recently discharged from the surgical unit called his doctor’s office. He told the nurse that he “felt sicker than when he was discharged.” He asked if he could get an urgent appointment to see the doctor, stating that “he did not want another ambulance and hospital bill to worry about.”

The nurse recognized the risk associated with this patient’s own agenda of wanting to avoid potential costs associated with treatment. She properly assessed his condition and concluded that the proper disposition was for the patient to be taken by ambulance to the nearest ED, despite his preference to avoid such a scenario.


In this case, the triage nurse was alert to an important risk-management issue. A patient’s concern over the cost of paying for care is a common situation experienced in telephone triage practice. In this situation, her disposition may have prevented the patient from suffering serious consequences due to the complications from his surgery.

Access to Specialists

While malpractice claims from traditionally high-risk populations (pediatrics, geriatrics, and women of childbearing age) remains high, what has changed is that many claims from high-risk populations are now related to lack of timely access to specialists. Due to cost-containment strategies, callers often need to be screened by their primary care provider prior to seeing a specialist. This policy may dangerously delay access to the patient’s OB/GYN, pediatrician, internist, or oncologist. Bureaucratic obstacles to timely access can be subtle.

Misguided Patients

Well-meaning but misguided patients often stereotype or mislabel their own symptoms and attempt to decide for themselves when they need to be seen (appropriately or inappropriately). They may base decisions on what is convenient or reasonable for them. This practice compounds the possibility of triage error, underscoring the need for RNs to elicit symptoms prior to appointment giving. Establishing a general policy that all symptom-based calls should be triaged by the RN may seem overly zealous but may actually help systems to run more efficiently and safely while avoiding risk.


An elderly man called the primary care nurse line, insisting on speaking with his doctor. The nurse responded that the doctor was on vacation until the following week. The nurse further inquired about the reason for his call, and the man stated that he was “probably fine and just needed to have his blood pressure checked.” As the nurse explored the patient’s symptoms further with more structured assessment questions about symptoms, severity, etc., she discovered that the patient had a history of high blood pressure and heart disease. Based on the assessment, the nurse recommended an urgent disposition to the ED.


In this case, the patient may not have recognized his symptoms as serious; indeed, he may not have experienced anything that he would even have considered a symptom. In the elderly, symptoms may be subtle or even silent. Perhaps, in this patient’s mind, he was simply calling to talk to his doctor, a trusted advisor, about the fact that he had been feeling tired.

If the nurse had not explored this patient’s symptoms further but simply arranged an appointment with the doctor the next week, a delay in care may have ensued, and the patient could have suffered further damage to his heart.


Telephone triage as a practice has evolved over the past few years and continues to have a strong presence within the field of managed care, primary care, and specialty practices. Telehealth nursing requires specialty skills, including a strong emphasis on communication, assessment, and critical thinking. Best practices, standard protocols, and decision-support tools continue to be critical components of the practice of telephone triage. These tools, partnered with the professional nursing judgment of an experienced nurse, provide an effective combination for the practice of telephone triage.


TeleTriage Systems (author’s website)


NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course (view/download PDF from the menu at the top of this page).

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O’Malley AS, Samuel D, et al. (2012). After-hours care and its coordination with primary care in the U.S. Journal of General Internal Medicine, 27(11), 1406–15.

Perrin E & Goodman HC. (1978). Telephone management of acute pediatric illness. New England Journal of Medicine, 298, 130–5.

Rutenberg C & Greenberg EG. (2012). The art and science of telephone triage: how to practice nursing over the phone. Pittman, NJ: Anthony Janetti, Inc.

Tuxbury J. (2013). The experience of presence among telehealth nurses. Journal of Nursing Research, 21(3), 155–61.

Wheeler SQ. (2013). Telephone triage research & “real world” practice. Retrieved from

Wheeler SQ. (2009). Telephone triage protocols for adult populations. McGraw Hill: New York.

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