Descriptions of triage vary. Transmitting information from the client to the provider so that the provider can make a decision regarding the care of the client is not considered triage. It is appropriate for nurses and unlicensed assistive personnel to transmit information to a provider.
Activities that involve interviewing, assessing, and intervening are accurately described as telephone nursing as defined by the American Academy of Ambulatory Care Nursing: “…telephone nursing practice…is practice using the nursing process to provide care for individual patients or defined patient populations over the telephone.” These activities fall within the legal definition of professional nursing practice or are otherwise restricted to the registered nurse (RN). Such activities include the functions of:
Providing a nursing assessment
Providing nursing care
Health teaching and counseling
Referral to other health resources
Implementing a condition-specific protocol
Evaluating these actions.
The level of nursing judgment and decision-making required to implement protocols help to determine how an LPN carries out telephone nursing. The following guidelines are intended to clarify telephone nursing practice by LPNs in the clinic setting:
Protocols, used by the LPN, must provide clear statements regarding what information to request of a caller and how to direct the caller to proceed. If the caller’s responses fall outside the protocol, the LPN should consult with the licensed practitioner who developed the protocol or refer the caller to an RN or a licensed practitioner.
The LPN may collect data from the caller using questions established in the protocol and determine the urgency of the call as defined in the protocol. If the caller presents multiple or complex problems, or the protocol results in a predetermined prescription, the LPN should refer the caller to a licensed practitioner or an RN for a comprehensive assessment.
LPNs who implement protocols in telephone nursing practice must recognize deviations from protocol criteria and report them to the licensed practitioner or an RN. They may, as directed by the protocol, transmit information to the caller.
If the protocol is condition-specific rather than developed for a named patient and results in a prescription for a legend drug, the LPN must transmit the information to an RN or the licensed practitioner for generation of the prescription.
The LPN should communicate the information to the licensed practitioner, including the caller’s response and/or outcome of the implementing the protocol. As with all nursing intervention, the LPN has a responsibility to document the caller information and results of the implementation of the protocol in the patient record.
The content of this document is based on the following Minnesota Statutes which may be accessed from the Laws and Rules section of the Board’s website:
Minnesota Statutes section 148.171, subdivisions 12, 14, and 15
Minnesota Statutes section 148.235, subdivisions 8 and 9
Minnesota Statutes section 151.01, subdivisions 16 and 23
Minnesota Statutes section 151.37, subdivision 2(a)
The Board suggests the following additional resources to determine whether persons involved in telephone interactions with clients are doing so appropriately:
The American Academy of Ambulatory Care Nursing Telephone Nursing Practice Standards: aaacn.inurse.com
The American Academy of Ambulatory Care Nursing, Nurse Licensure Compact (NLC) Position Statement: https://www.ncsbn.org/positionStatementNLC.pdf
National Council of State Boards of Nursing Working with Others: https://www.ncsbn.org/Working_with_Others.pdf
Publications and websites regarding telephone/triage nursing, such as:
• Sheila Quilter Wheeler, Telephone Triage: Theory, Practice, & Protocol Development, Delmar Publishers, Inc., Albany, New York, 1993
• Carol D. Rutenberg, “Telephone Triage,” American Journal of Nursing, March 2000, pp. 77-81
• Telephone Triage Consulting: www.telephone-triage.com
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