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Documentation Let’s make it easier! This applies to triage…. This is what is required in the triage process…. Triage time, historian, PCP and how they arrived . Chief complaint (this will look different depending on your template choice) Pain level must be documented!.
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This is what is required in the triage process… Triage time, historian, PCP and how they arrived
Chief complaint (this will look different depending on your template choice) Pain level must be documented!
Any treatment by EMS prior to arrival, Meds and Allergies
THIS IS REQUIRED! All you need to do is click on it-that tells us you have assessed their RISK for skin integrity, not completely undressed them and seen all their skin All the other questions are NOT required (unless they declare themselves as suicidal)
Vital signs, weight and Sepsis screen-do at least the temperature, HR, and respiratory rate for the sepsis screen
For checking in an ambulance or if you can’t get to computer…