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Table 2 shows the differences in triage documentation when measured by AAACN documentation criteria and by triage document content.
We reviewed the triage document content using several different measures.
Table 4 shows the triage document cohorts were well matched for gender and triage recommendations.
The triage document selection process was done sequentially by nurse and so the type or severity of the symptom being addressed was not expected to show any cohort bias.
In addition to supplying clinical decision support, ExpertRN automatically constructs a triage document that records the symptom assessment questions and responses that the nurse checks off while going through the branching logic.
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A study by Derkx using incognito patients and comparing recorded calls with triage documents found that the triage documentation at times did not match what was heard on the recorded call [ 22].
Triage documents produced with CDS also had more documentation of symptom features and so had better documentation of how the nurse arrived at the disposition.
Of the self-referred cases in our sample, 897 (57.1%) had triage documented: 81.8% of these cases were yellow or green.
We examined 50 triage documents before and after a CDS tool was used in nursing triage.
This was a retrospective study of telephone triage documents in electronic medical records.
Triage documents authored by nurses trained in CDS but not using it showed no significant improvement.
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Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com