However, patients who have cognitive impairment from drug use, alcohol use or mental illness are at risk from adverse events in such situations. The Triage Nurse must therefore consider their duty of care in such cases.
The Triage Nurse must be aware of his or her responsibilities with these patients and abide by any local policies or protocols.
Negligence
Negligence laws vary between states and have recently undergone significant changes. Nurses have a responsibility to behave in a reasonable manner. If there is any breach from this responsible approach which results in some type of injury to another, this breach constitutes negligence.
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For negligence to be proven it requires the establishment of all of the following elements:
• Duty to meet the standard of care
• Breach of the duty to meet the standard of care
• Breach of that duty which causes foreseeable harm
• Causing actual harm and injury
• Causing loss.
Documentation requirements
Communication with and by the staff leads to increased information shared and clear advice given. Medical records are a method of communication for health care team members and are a contemporaneous record of events. They must be accurate, clear and succinct. It is also expected that the records will be easily accessible and able to be understood.
Documentation of each interaction between the nurse performing triage and the patient and / or significant others are another area of accountability for practice. The Australasian College for Emergency Medicine( ACEM) is clear in its guidelines about the minimum information that is required to be recorded for any triage episode.
Documentation standards that are required by ACEM are:
• Date and time of triage assessment
• Name of the Triage Nurse
• Chief complaint / presenting problem
• Limited relevant history
• Relevant assessment findings
• Initial triage category allocated
• Re-triage category with time and reason
• Assessment and treatment area allocated
• Diagnostic, first aid or treatment initiated at triage.
Any change in the patient’ s condition should be documented clearly. This documentation should include the time of the re-triage, the reason for the re-triage and who was responsible for the performance of the re-triage.( See‘ The Challenge of Triage’ on page 25 of Chapter 4.)
Department of Health and Ageing – Emergency Triage Education Kit