Telephone Triage Nursing


Telephone triage nursing is the nursing process conducted via the telephone. Using the process of assessing, planning, implementing and evaluating, the registered nurse uses an established method to meet the needs of the client. During a telephone encounter, the nurse engages the client in an interactive interview to assess a patient's health status and to offer recommendations for treatment and referral. The goal of telephone triage is appropriate patient referral to the appropriate level of care within an appropriate period of time.

Telephone triage systems originate from many settings, including:

Services offered vary as much as the settings. Services range from general "helplines" to subspecialty (i.e. cardiology, hematology, oncology, etc.), after-hour lines to organized services that assist callers with their access to necessary health care.

The educational and clinical background required for the person performing in the telehealth setting varies depending on the type of service to be delivered. The standard, offered by the American Academy of Ambulatory Nurses, indicates that a professional telehealth nurse plans, delegates, supervises and evaluates nursing care, given by support staff in accordance with applicable statutes, nursing standards and organizational policy. In addition, a competent registered nurse will manage all telehealth encounters requiring assessment.

Some programs require RN certification in the specialty area (i.e. emergency nursing, nephrology nursing, etc.) In addition to RNs, some programs may use unlicensed assistive personnel (UAP) to perform tasks delegated by the RN. These duties must be restricted to tasks which do not require assessment, such as: documenting initial patient demographic data or obtaining patient medical records. In all cases, nursing care delegated by a professional nurse must be in accordance with applicable statues, rules and regulations of the state, territory or commonwealth and be within accepted standards of nursing practice and institutional policy.


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Telephone triage programs require all personnel to be certified in appropriate specialties.
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Visit the Victorian Order of Nurses website for an international perspective on telephone nursing.

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