Telephone Triage Process

There are 6 steps to the telephone triage process:

1) introduce oneself and establish a rapport,

2) conduct the interview/assessment,

3) make a triage decision using an established protocol or guideline,

4) offer the predetermined advice,

5) conclude the call and follow-up as needed,

6) document the call.

Introduce oneself:

The nurse begins the call by introducing herself/himself by name and title. This information provides the caller with the confidence that the advice is given by a warm, compassionate and knowledgeable professional. Opening the communication between the nurse and the patient begins with this simple act of developing trust and allows for the establishment of a rapport. The nurse's caring voice and nonjudgmental manner sets the tone for the entire call. The trust gained during the initial communication encourages the caller to reveal information, thus allowing the nurse to make informed decisions about the patient's health.

Conduct the interview/assessment

When triaging over a telephone, the nurse relies solely on listening, using intuition and nursing knowledge (Perry, 1993). The telephone triage nurse listens to what the caller is saying, what the caller is not saying, and is alert for oral cues. The caller's breathing pattern or the pauses in their sentences may give important insights into the caller's anxiety level. Background sounds, conversations, activity such as a crying infant or a shouting family member may clue the telephone triage nurse in to the pressures the caller is facing at home (Banks, 1991). The telephone triage nurse may ask the caller to bring the phone to the patient and listen carefully for signs and symptoms such as coughing, wheezing, congestion, a muffled voice, shortness of breath, pain, fear, and other indicators of a problem. Whether listening to the respirations of an 18 month old or discussing an adolescent's abdominal pain, the telephone triage nurse relies solely on an ability to listen and interpret.

The interview follows many of the same guidelines used in any other patient setting. The interview provides data that forms the basis for the nurse's assessment. Thus, the interview must be concise and focused. Information obtained from the patient includes demographic data, baseline health information, and current symptoms.

Demographic Data

Baseline Information

Patient name Caller's name & relationship to patient
Date of birth Birth weight (for neonates)
Telephone number Birth history (for neonates)
Weight (pediatric patients) Type of insurance (for referral purposes)
Primary care physician Medications (prescription, OTC, alternatives)
Today's date Medication allergies
Immunization status Past Medical/Surgical history
Important times:
  • when caller phoned service/hospital
  • when triage nurse began speaking to the caller
  • time call finished
  • notification of 911, MD, ED, etc.


P Provoking Factors
  • What makes it (pain, breathing, etc.) worse?
  • What makes it better?
Q Quality of Pain
  • What does it feel like?
  • Has the patient ever experienced pain like this before?
R Region/Radiation
  • Where is the pain?
  • Is it in one spot?
  • Does it start in one spot and travel to another?
S Severity of Pain
  • Is this the worse pain ever experienced?
  • If abdominal pain, is the pain worsened with movement such as climbing stairs, jumping on one foot or riding in a car?
T Time
  • When did it start?
  • How long have the symptom(s) persisted?
  • How long did it last?
  • Has it ever happened before?
T Treatment
  • Has the patient been given any medication to treat this?
  • What time was the last dose?
  • Has the patient tried any home remedies?
  • What has/has not worked for the patient?


Make a triage decision using an established protocol or guideline

Once the assessment is completed, the appropriate triage protocol or guideline is selected. These protocols ensure that advice given to the caller is consistent and precise. The protocols can be generated from a computer-based system or a manual system of reference texts and paper reports.

Following the protocol guidelines, the triage nurse advises the caller as to the type of care needed for the patient at that time. The ultimate decision regarding care rests with the caller.

There are times when a caller's description may not "fit" into a particular protocol. The caller may communicate in a vague manner, or the caller's concern or timing may seem inappropriate. The triage nurse must take special care with these callers, question precisely, and listen carefully to determine their main concern. Once the concern is identified, the triage nurse should follow the protocol which most closely matches the patient's symptoms, and manage the call with a very conservative approach (Brown, 1994, and Simonsen, 1996). If physician back-up is available for the triage program, the nurse may choose to review the call with the physician, or may call the caller back to follow up on the condition of the patient. Click here to access sample protocols (Fever, Abdominal Pain, Rash, Difficulty Breathing and Chemicals in the Eye).

Offer the predetermined advice

If advice is given, the telephone triage nurse assures that the caller clearly understands the advice by having the caller repeat the information back to the nurse. Whether the advice is to "call 911 now" or about how to manage vomiting at home, the nurse must be clear and simple when giving directions and be comfortable that the caller understands the information.

The nurse offers positive reinforcement whenever possible to help alleviate apprehension and heighten the caller's comfort level in caring for their sick or injured family member.

Conclude the call and follow up as needed

When concluding a call, the telephone nurse always encourages the caller to call back if symptoms persist, worsen, change, if new ones develop, or if anything occurs that heightens their concern. Callers tend to be more comfortable with their telephone advice if they believe that the telephone triage nurse is easily accessible. The telephone triage nurse has the additional option of calling the caller back to follow up on the condition or the understanding of any advice previously given.

Document the call

Documentation of each call must be precise, and follow the protocol used. The most comprehensive style of documentation is by inclusion. In this style, all pertinent negatives are listed and thus creates a clearer picture of the patient scenario. Click here to see sample documentation tool.

Instant Feedback:

When documenting a call, include all data and as much information as possible to give a complete patient scenario.