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RN Triage Documentation in an Ambulatory Care Setting: A

Nurse Driven Data Collection Tool

Jason Eagle, RN, BSN Central Arkansas Veterans Healthcare System

Purpose

The purpose of this activity is to enable the learner to understand the benefits of an RN triage documentation tool and its impact on productivity and cost savings in an ambulatory healthcare setting.

OBJECTIVES • 1. Describe the need for a standardized RN triage

documentation tool in the ambulatory setting.• 2. Discuss the process for implementation of a

new documentation tool.• 3. Describe the evaluation plan for updating a

documentation tool.

Background• The ambulatory setting is where the majority of

patients receive healthcare in the United States. • RN projected employment is expected to grow

exponentially in the ambulatory healthcare setting.• Health care delivery in the Unites States requires

fundamental redesign to become effective, sustainable, and cost-effective.

(Rondinelli et al., 2014; Smolowitz et al., 2014)

RN Impact in Ambulatory Care

Nurse-sensitive outcomes and quality indicators.

• Hospital readmissions

• Quality of life• Functional ability• Self-care abilities

(Rondinelli et al., 2014

Benefits of Ambulatory Care

• Improved patient health outcomes• Reduced health disparities• Efficient spending of healthcare dollars

(Smolowitz et al., 2014)

Setting

• Community Based Outpatient Clinic (CBOC)– Searcy

• Primary Care facility dedicated to providing care to Veterans

• Approximate size 3400 enrolled Veterans• Typical scheduled daily 35 (3 Providers) with

additional same day access appointments made

Identified Problem

• The Joint Commission (2014)• Inconsistent documentation by RN staff• Inability to locate specific modifiers• Omitted data

What does it mean for you?

RN Triage Template

Goals for Implementation • Streamline documentation for nursing staff

involved in the Primary Care setting• Follow guidelines related to the Nursing Process,

as outlined by the American Academy of Ambulatory Care Nursing

• Provide a consistency in charting for all RN’s delivering care, within the service

• Decrease patient wait time• Provide a better clinical picture of present

symptoms for provider• Provide an accurate and thorough data collection

system

How does this comply?

The Nursing Process…

• 1. Guided by Critical Thinking• 2. Accurate and Thorough Data Collection • 3. Integration of Data and Information at Every

Step• 4. Provides Organized Framework• 5. Theory and Research Based• 6. Not Static, Fixed, or Linear• 7. Provide a Feedback Loop• 8. Documentation

1. Guided by Critical Thinking

• Defined as: • “The ability to think in a systematic and logical manner

with openness to question and reflect on the reasoning process, used to ensure safe nursing practice and quality care (Laughlin, 2013).”

• Problem-solving and decision-making are crucial skills

• Critical Thinking is thought to be the most essential of all nursing competencies

2. Accurate and Thorough Data Collection

• Assessment is the first of five steps in the nursing process• Defined as:• “Systematic collection of data to determine the patients health

status and to identify any actual or potential health problems (Laughlin, 2013).”

• Incomplete data collection can lead to errors in decision making and possibly the wrong treatment for current conditions

• “In the assessment phase of the nursing process; obtaining, classifying, and organizing data is the main function of critical thinking (Laughlin, 2013).”

3. Integration of Data and Information at EVERY STEP

• Classify data, grouping significant and related data

• Create a list of suspected problems• Rule Out similar problems using critical thinking

skills• Determine risk factors that must be managed

• Includes Objective and Subjective data through the measurement of physical data and examination

4. Provides Organized Framework

• Document data in a Systematic manner• Problem focused• Structured and Accurate assessment data to

delineate responsibility• Provide a basis for Consistency• Describe steps and actions in exact order

5. Theory and Research Based

• Directly complies with • Core curriculum for ambulatory care nursing (3rd ed.).

Pittman, NJ: American Academy of Ambulatory Nursing. (14).

6. Not Static, Fixed, or Linear

• Based on Current Best Practice• Does not supersede clinical judgment• Aimed to achieve BEST OUTCOMES• Allows for data to be personalized to meet patient

specific care needs• Template serves as a framework for data

collection based on the standards of care that guide our nursing actions

7. Provides a Feedback Loop

• “Organize, Synthesize, and Summarize assessment data (Laughlin, 2013).”

• Provide an accurate clinical picture for provider to determine needs in a more structured and objective framework

• Data systemically displayed, Problem Focused

8. Documentation

• A crucial step in the nursing process • Used by nurses in all settings of care• Provide uniform framework to create a basis for

consistency

Goals and Outcomes

Clarification…

• Provide a basis for Consistency• Describe steps and actions in Order• Delineate Responsibility• Do not supersede Clinical Judgment• *The current charting used does not meet these goals and

outcomes; allowing significant error and omission of necessary assessment data. Most information is entered by RN without guidance in assessment criteria. • *All charting should have the same framework and outline

similar data within the Ambulatory Care Setting.

Guidelines

• Based on Standards of Care that guide nursing actions

• Based on Current and Best Practice

• Aimed to achieve Best Outcomes

The Template at a glance

Where to find it?

Each section contains additional assessment data within the system

Vital Signs Populated

Select Location

Chief Complaint

Allergy Assessment

The Problem is not one of the outlined systems?

Use the “Additional Information” Section to free type problems patient presents with today.

Do I have to complete the whole template?

• NO, you do not have to complete each section of the template.

• Sections that must be Completed:• Provider and Location• Chief Complaint• Allergy Assessment• Pain• Assessment Data• Plan

• Designed to be Problem Focused

Outcomes

• Provide an easy to use, conclusive, and up to date charting framework that meets the Academy of Ambulatory Nursing Guidelines.

• Streamline problems in a system by system manner to focus on immediate needs

• Decrease time spent by provider gathering assessment data, by providing a better clinical image of patient initially

• Concise charting throughout the service• Guide nursing staff in assessment • Allow for personalized and appropriate care for

our patients

Data Collection…•1 Month •3 Clinics•1 clinic-no template•2 clinics-problem focused template

How will this affect you?• No Template Used: • 16 patients average time with provider of 524 Minutes

creating a yield of 8.73 hours spent in a 1 Month time frame for overbooks. This later yields a yearly total of 104 hours spent.

• Template Used:• 16 patients average time with provider of 165.6 Minutes

creating a yield of 2.76 hours spent in a 1 Month time frame for overbooks. This later yields a yearly total of 33.12 hours spent.

• When the template was used; time spent by provider on overbooks was REDUCED by 68%.

Access of Care• By a change in documentation, it will allow access

to 34 more patients per month (417 patients/year, PER PROVIDER), without any change in time spent with those patients.

References• Laughlin, C. B., & American Academy of Ambulatory Care, N.

(2013). Core curriculum for Ambulatory Care Nursing. Pitman, NJ: American Academy of Ambulatory Care Nursing. 192 (14). Retrieved from EBSCOhost. (s8897724).

• Rondinelli, J.L., Omery, A.K., Crawford, C.L., & Johnson, J.A. (2014). Self-reported activities and outcomes of ambulatory care staff registered nurses: An exploration. The Permanente Journal, 18 (1), e108-e115.

• Smolowitz, J. et al. (2014). Role of the registered nurse in primary health care: Meeting health care needs in the 21st century. Nursing Outlook, 63, 130-136.