Triage Workflow

View the video above and/or read through the text below to learn how to document for the SMLC triage and medical history station! Please let us know if you have any questions.

When patient is ready for triage, he/she will be marked orange and the line say “Ready for Staff” (aka Ready for Triage). After the patient is selected, go to right upper corner and select “Go to Intake.” Before moving forward, please ask patient to state his/her DOB to confirm correct chart is pulled up.

Before beginning asking questions or taking vitals, please change “patient status” and “patient location” at the top of your screen to reflect his/her current status.

After each tab is completed, you may select “Next” in the right corner or select the subsequent tab in the left column. Note: All entries are saved automatically.
Please complete the following areas (if any areas unknown, simply click “Add” with as much information as possible):

1. Reason for Visit (aka chief complaint)
   1. Click the “+” symbol to add reason
      1. Note: each chief complaint must be added in separately (click the + again)
2. Patient preferences
   1. Encourage patient to sign up for the online portal
   2. Pharmacy: completed by intake
      1. If not yet added, include patient’s preferred pharmacy since SMLC providers can now electronically prescribe
   3. Preferred lab: completed by intake
      1. If not yet added, indicate LabCorp PSC for all patients (LabCorp site at 1932 Alcoa Hwy., Knoxville, TN 37920).
   4. Preferred imaging facility: leave blank
   5. Care Team:
      1. If in Athens, ask if patient goes to Hiwassee Mental Health. If so, please include under Care Team (click “+” then type “psychologist,” then you will be able to type “Hiwassee Mental Health.”)
      2. If in Decatur, ask if patient goes to Rhea Mental Health. If so, please include under Care Team (click “+” then type “psychologist,” then you will be able to type “Volunteer Behavioral Health.” Click option in Dayton.)

3. Vitals
   1. Please complete Ht (height), pain scale, pulse, RR, T, Wt (weight), BP, and O2Sat (other areas may be left blank).
      1. Note: Any red text indicates an abnormal reading. Please retake any abnormal values (if BP high, please wait 5-10 minutes and then recheck with manual cuff).
   2. If appointment is for new patient, diabetes, or annual PE, complete blood glucose testing. Go to “Orders and Results” (towards bottom of left side column).
      1. Select the “Plus” symbol, then under “Point of Care” (you may need to select the arrow for more options) select “glucose, fingerstick, blood.” Click on this order, and it will bring up the result page for completion.
      2. Include food consumed prior to visit in the “Note” section.

4. Allergies (include reaction and severity)
5. Medications (include dose, frequency, how taken, when, & start date (as applicable))
   1. Refills are taken care of by the provider, so triage does not need to worry about this information.
   2. If patient is no longer taking medication, click on the “X” then click “STOP”
   3. To minimize individual medicine info, click on the name of medication to make it smaller.
6. Vaccines (include influenza, COVID19, Td/Tdap booster, & pneumovax)
7. Problem List – completed by Provider
8. Family History (Please do not include age for “Died” unless he/she died of this condition.)
   1. Note: If patient is established, only need to ask if any changes since last visit.

9. Social History
   1. For new patients: please ask all questions
   2. For returning patients:
      1. ADLs: review once per year at annual PE
      2. Substance abuse: review every visit
      3. Diet & exercise: review every visit
      4. All other questions: do not need to be re-asked
      5. COVID questions: complete every visit
   3. Note: To enter COVID screening questions, click the “+” next to Social History, then click “Care Management” (if not yet checked). Then COVID questions will be included at the bottom of the social history questions.

9. 4. Advance Directive: if the patient is not familiar with advance directives or a medical power of attorney, please explain as below (Note: if patient would be interested in completing either of the below, please include in the “Note” and notify the Nurse Manager)
      1. Advance Directive: written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure wishes are carried out should the person be unable to communicate them to a doctor
      2. Medical Power of Attorney: legal document that names one person the healthcare agent of another person if he/she becomes incapable of making those decisions themselves. The agent has the ability to make health care decisions and the responsibility to make sure doctors and other medical personnel provide necessary and appropriate care according to the patient’s wishes (includes end-of-life care).
10. Surgical History (with date if known)
    1. Note: If patient is established, only need to ask if any changes since last visit.
11. For female patients:
    1. Gynecological history
    2. Obstetrics history
    3. Past Pregnancies
12. Past Medical History
    1. Click “Yes” next to items of which the patient has a history (it is unnecessary to click “No” for other items).
    2. Update every visit with the following: Hospitalizations since last visit, last seen in ER, and other major changes (do not need to re-ask every item)
13. “Screenings” & “Quality Measures”: at this time, will not be completed 
14. HPI: You may include a brief note if desired.
15. “Review of Systems” & “Procedure Documentation”: at this time, will not be completed.