The Nursing Process as the Basis for Telephone Triage

A transcript taken from Carol Rutenberg’s video The Nursing Process as the Basis for Telephone Triage.

The nursing process is the basic standard of care for our profession, regardless of the specialty or the setting, but its applicability in telephone triage isn’t always understood. So I’d like to share how it applies and how it provides a structure for our triage calls.

As a quick review before we start, the six steps in the nursing process are:

  1. Assessment
  2. Diagnosis
  3. Identification of desired outcomes
  4. Plan
  5. Intervention, and
  6. Evaluation.


So the first step in the nursing process is assessment. The assessment has two parts, not just subjective but also objective. Many nurses believe that you cannot do an objective assessment unless you’re at the patient’s bedside, but I’m going to show you how that’s possible. The subject of assessment is simply the patient history, and you get that by talking to the patient or caller – and I do suggest that you always talk to the patient. And then use of excellent listening skills and practiced interviewing techniques will get you a pretty complete picture. However, the picture is not complete without the objective data, which is equally important but often overlooked.

A quick and easy example of the importance of this objective data collection can be illustrated in the case of a patient who has been vomiting for 24 hours. Perhaps you tell me that they vomited eight times in 24 hours. That doesn’t tell me much except that the patient has been miserable for a while. What is greater in significance is the nature of that emesis and the patient’s hydration status. Be sure to ask and document this information.


The next step is the diagnostic statement. Although we don’t provide a medical diagnosis, we do develop a diagnostic statement, which refers in telephone triage to the nature and urgency of the patient’s problem along with any relevant compounding factors.

Going back to our vomiting patient, in the event that she’s dehydrated the diagnostic statement might be “urgent vomiting with compromised hydration status”. An additional element of the diagnostic statement would include any confounding factors that the patient has such as reluctance to seek care, lack of transportation, or inability to hold down any liquids.


The desired outcome is important because there are several different ways to develop a plan of care for most telephone triage patients. In order to pick the appropriate plan out of the range of possible interventions, it would be important to think through “what do I want to accomplish for this patient”. So let’s go back to our dehydrated patient and our objective: our desired outcome would be for them to be effectively rehydrated.


So moving on to the plan, if the patient is able to hold down PO liquids then home care might be appropriate given that all potentially life-threatening causes of vomiting have been ruled out. However, for the dehydrated patient who is unable to hold down PO liquids, they would need to be referred for definitive care which would probably include parenteral rehydration.

Where the patient will be sent for this will depend on such factors as time of day, distance from care, available transportation and other resources. So if you don’t want to rehydrate these patients in your clinic you probably will want to send them to an urgent care or emergency department via appropriate transportation.


In implementing the plan of care, it’s important to give attention to continuity of care. This is because we must recognize that we are not the end point of care for our patients. If you’ll think about it you’ll realize that we’re not actually able to do anything directly to or for our patients. Someone else must do that. Even when we’re providing the patient with good health information, all we’re doing is preparing them to care for themselves now or at a later date. So it’s important that any intervention includes adequate patient instruction, and then also calling report if you refer the patient elsewhere.


Finally, we need to evaluate the effectiveness of our actions. In the case of a low risk caller where we have reason to believe that they’re going to comply with the plan of care, it’s generally sufficient to just tell them to call back if they don’t get better and to give them parameters to watch for. However, in the situation of a high risk problem in which we’re not certain that the patient is going to comply with the plan of care, then the nurse probably needs to proactively call that patient back to evaluate the effectiveness of the actions and to be sure that the desired outcomes have been achieved.


So in summary, assess the patient, diagnose the nature and urgency of their problem, identify desired outcomes, develop a plan, carry out that plan, and then evaluate the effectiveness of those actions. These six steps, if faithfully applied, will provide the framework for your telephone triage calls and let you identify and meet your patients’ needs safely and professionally.

Carol Rutenberg is a nationally recognized expert and speaker in the field of telephone triage. To learn more from Carol about the ideas in this video, you can refer to The Art and Science of Telephone Triage written by Carol and her colleague Liz Greenberg and endorsed by the American Academy of Ambulatory Care Nursing. This video training series was produced and sponsored by ClearTriage, an online version of the Schmitt-Thompson telephone triage protocols that is compatible with Carol’s teachings and widely used as a decision support tool for telephone triage nurses and practices and clinics.

Carol’s training is also the basis for the American Academy of Ambulatory Care Nursing’s Telephone Triage Course which is available for purchase and eligible for 17.5 continuing education hours.

ClearTriage is a web-based decision support tool for telephone triage nurses and the leading provider of the Schmitt-Thompson telephone triage protocols. ClearTriage offers several technical integrations including SSO, embedding, structured data return, and translation. Contact us to learn more or start your 30-day free trial today.

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