The Triage Nurse should be aware of the management systems in place at the individual institutions to facilitate this documentation.
Similarly, if it is the practice of the institution to transfer the care of patients to other health care providers such as general practitioners, accurate and concise documentation of any treatment administered and any recommended course of action should be made.
Some patients choose to leave prior to medical assessment. If such a patient advises the Triage Nurse they are not waiting, the Triage Nurse should document this decision, as well as any advice given to the patient, including possible adverse outcomes.
Confidentiality
Health professionals must maintain any information that has been provided in-confidence to them. It is also expected that the patient is in receipt of privacy from health professionals. Safeguards are in place to protect patient’ s information. These include health legislation at both federal and state level.
The Triage Nurse also has a responsibility to ensure the patient’ s privacy is respected both during the triage assessment and while the patient waits in the waiting room. The hospital policy regarding patient’ s privacy and rights should also be readily accessible to the Triage Nurse.
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A health care professional is obliged to treat the patient’ s medical information as private and confidential. However, in certain circumstances there is a legal requirement to override a patient’ s privacy and confidentiality; for example, children at risk. Otherwise, a breach of a patient’ s privacy constitutes a breach of the duty of care.
Mandatory reporting responsibilities
If there is any suspicion that a child or children may be in need of care or may be being maltreated, the nurse has a legal responsibility to report it to the relevant authorities and refer to their jurisdiction.
Although this reporting may not occur from the triage desk, the nurse needs to be aware of the legal requirements and of the procedures and documentation requirements of the hospital, in order to fulfil these obligations.
Preservation of forensic evidence
Nurses performing the triage role must be familiar with the hospital’ s procedures for dealing with the preservation of forensic evidence involving a patient who is a possible victim of crime( e. g. rape or assault). These procedures should include liaison with police officers as appropriate, with the patient’ s consent.
Department of Health and Ageing – Emergency Triage Education Kit