From: Astrid M. Newell, M.D.
SBHC Clinical Coordinator/Physician Consultant
Oregon Health Division

Currently, many visits to SBHC's are for the management of minor symptoms or complaints. These visits are affectionately referred to as "triage visits". Triage visits are usually provided by the SBHC nurse, and typically are not considered measurable "encounters". Some sites do not consistently record these brief visits in patient charts or in official chart-compatible triage records. Due to the large volume of these visits at many sites, a significant amount of service information is missing if these are not recorded and if the data is not collected. There are also liability issues if services provided in the SBHC are not properly documented. The purpose of the following document is to provide guidance to SBHCs on "triage visit" policies and procedures, documentation, and coding.

Definitions

Triage, in its broad definition, is the systematic process of assessing/screening a patient's complaint or symptom for severity and subsequently determining an appropriate course of action.

For SBHC purposes, triage visits will be defined as brief patient encounters with either a nurse or a medical provider for the assessment of symptom urgency and recommendations for either further medical evaluation or minimal intervention (which might be considered home or self care). Through a brief symptom assessment protocol (questioning), the nurse or provider will determine the severity of the problem and recommend appropriate measures. Other than advice and simple measures such as the use of over-the-counter analgesics, Band-Aids, ice-packs or use of the resting area, no other significant intervention is performed. The visit will usually take less than 5-10 minutes and would normally not be a billable service. If a visit or decision-making process is more complex or would be considered a billable service, it should be addressed as an office visit. Another way to think of "triage visits" is those visits which serve a "school nurse" function.

Triage Policies /Procedures

SBHCs must have written triage policies and procedures, which include staff roles and responsibilities, specific symptom assessment protocols, standing orders (e.g. Tylenol for headaches) and documentation methods.

Policies must clarify the role and limitations of the unlicensed personnel (e.g. health assistants) in regards to triage functions. In general, triage services should be provided by a licensed nurse or provider. (See further guidance on health assistants and medication administration.)

Symptom assessment/triage protocols* and standing orders should be developed and reviewed by the SBHC nurse as well as the supervising medical provider, modified (if needed) and signed by the medical provider at least annually. ·

There are a number of sources of triage protocols, mostly designed for telephone triage nurses and emergency room nurses, which might serve as a basis for some SBHC protocols. One example is Briggs, Telephone Triage Protocols for Nurses, Lippencott, 1997.

Triage Documentation

There are two different ways that "triage visits" may be documented, either in a separate triage record or in the chart. Many sites have chosen to document only office visits (typically by the nurse practitioner or other provider) in the chart and maintain a separate electronic file, paper file, or notebook of the nurse triage visits.

If a site chooses to use a separate triage record system, the following are key components:

- separate record for each individual patient

- ability to pull up a record by name or identification number

- visit information attached to or stored with parent (or student) consent

- documentation of medication allergies or other serious medical conditions

- documentation of emergency contacts

- inclusion of visit dates, providers, complaints, treatments, provider signature/initials

- hard copy compatible with chart (so can later be filed with chart)

Advantages of a separate triage system include decreased storage space required, decreased time spent pulling charts, and relative ease of use. Disadvantages include not having all of an individual patient's health information in one location for improved health tracking.