Documentation for Nurse Calls
Capture a triage call so the provider can act on it — concise, complete, and clear about urgency and what you did.
Learning Objectives
- 1.Document a nurse triage call clearly and completely.
- 2.Record the information a provider needs to make a decision.
- 3.Document escalation, advice given, and follow-up.
Purpose
A call note is how your triage becomes actionable. If it isn’t documented, it didn’t happen — and a vague note forces the provider to call the patient back from scratch. Good documentation protects the patient and you.
What to document
- •Who called and the reason, in the patient’s words.
- •Symptoms, timing, severity, and any red flags screened.
- •Relevant vitals/weights and pertinent history.
- •Your assessment of urgency.
- •Advice given, who you escalated to, and the plan/follow-up.
What meds/labs matter to note
- •Any new, changed, missed, or run-out cardiac medications.
- •Recent or pending labs (e.g., INR, BMP/potassium, lipid results).
- •Anticoagulation status if bleeding or a procedure is involved.
Document the escalation
- •Time of the call and time you escalated.
- •Who you contacted and how (message, direct, on-call).
- •The shared plan and any instructions given to the patient.
Close the loop in writing
Note the response to your escalation and the follow-up plan. "Left message, no response" is itself important to document — and to keep following up on.
Mini case
You triage a call, advise the ED, and message the provider. You write: "Patient called, told to go to ER."
What’s missing?
Show answer
Almost everything a provider needs: the symptoms and timing, red flags, vitals, your urgency assessment, who you escalated to and when, and the follow-up plan. A complete note lets the next person act without re-interviewing the patient.
Checklist
- Reason for call in the patient’s words.
- Symptoms, timing, red flags, vitals, relevant meds/labs.
- My urgency assessment and the advice I gave.
- Who I escalated to, when, and the follow-up plan.