In order to practice safe, effective telephone triage, it is essential for the telehealth nurse to perform a comprehensive assessment upon which to base the plan of care. This manual includes 118 clinical templates to support a systematic, comprehensive assessment of your patient over the telephone.
Designed as an adjunct to a comprehensive set of decision support tools (protocols)*, Carol Rutenberg’s signature system for patient assessment leads the nurse through a rapid assessment of potentially life-threatening problems (ABCD), a structured history of the present illness (POSHPATE) and then a structured review of possible causes of the problem/differential diagnosis (TICOSMO) to assure that important findings are not overlooked. Objective parameters are also suggested that will guide the nurse in performing a limited “physical assessment” of the patient.
*These assessment tools are included in the 2005 edition of Telephone Triage Decision Support Tools for Nurses: Guidelines for ambulatory care by Dale Woodke, published by Ambulatory Innovations.
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