8.20 Telephone Triage Standards in Ambulatory Clinics
Category: UWHC Departmental Policy
Policy Number: 8.20
Effective Date: September 24, 2014
Section: Patient Care (Ambulatory)
To define the standard process in UWHC clinics for delivery of telephone nursing services.
The nursing process is used to gather information, critically evaluate the information, act appropriately, and
evaluate the outcome of those actions. The nurse applies active listening skills; listening to verbal and non-verbal
clues, and questioning the caller to elicit further information. The nurse utilizes a strong clinical knowledge base as
well as decision support tools and protocols.
Ambulatory clinic Registered Nurses (RNs) are responsible for assessing and triaging patient health concerns,
evaluating patient data, applying the nursing process, assisting in resolving the patient’s concerns and delegating
duties as necessary. RNs use a holistic approach in collecting information about the caller’s description of physical
symptoms, an impression of the caller and a sense of context. The nurse uses picture building to attempt to
construct a mental image of the caller and their situation. The nurse balances patient safety needs against
available resources for care and facilitates access to the most appropriate care resource. The RN will follow
protocols, guidelines, practice standards and/or confer with the provider for direction. The Medical Assistant
(MA), Scheduler, Licensed Practice Nurse (LPN) and Student Nursing Assistant (SNA) may gather information for
the RN or provider by phone but do not make an assessment or decision about patient disposition.
1. Phone calls and messages will be reviewed throughout the day, prioritized within the same
working day, and returned as appropriate. If unable to complete within the day, an attempt will
be made to contact the caller with the status of the call.
2. Patients are encouraged to direct their calls requesting prescription renewals to their pharmacy
who will fax the request to the prescriber’s office. An RN may renew a prescription under clinic-
specific protocols. See Primary Care Prescription Renewal Protocol and Ambulatory Delegation
Protocols on UConnect. The goal is to complete prescription renewals within two working days. If
extenuating circumstances exist, the patient will be notified at the time of the call or in a
subsequent call when to expect the renewal to be completed. The caller should be asked to leave
a phone number where a message may be left. Support staff (MA, LPN, SNA) may fax or call in
renewals that have been signed, indicating approval by the RN, Nurse Practitioner (NP),
Physician’s Assistant (PA) or physician.
3. After Hours Triage - Main clinic phones are programmed to be forwarded to the Paging Message
Center at the close of clinic. Patients of Internal Medicine, Geriatric and Pediatric physicians will
be offered the UW Health Line Nurse Call Center after hours.
4. Phone Calls
a. UWHC will make phone calls using the patient’s, the patient’s legally authorized
representative, or the guarantor’s/subscriber’s home and/or work phone number.
Exception: May use an alternate number that the individual requests UWHC to use for
a specific call.
b. Communication should be made directly with those contacts listed above or with the
patient’s emergency contact when appropriate. The patient may also give permission
(this can be verbal and should be documented) to speak with someone else. Steps
should be taken to verify that it is the patient giving permission by asking for birth date
and/or medical record number.
c. If it is necessary to leave a message on an answering machine or voice mail, leave the
minimum amount of information necessary to communicate the message (see UWHC
Administrative Policy 6.24 - Communication with Patients Outside of the Clinical
Setting). If the patient has given permission to leave a more detailed message, staff
must document this permission. Staff will encourage patients to fill out and sign the
Authorization for Verbal Communication and/or to Leave Voice Mail Messages UWH Form
d. The following information should not be left on an answering machine or voice mail
unless patient permission has been granted and documented:
i. Name of clinic or department (Exception: clinic or department name can be
left to avoid a “no show” or because the patient has more than one
appointment in close proximity to each other);
ii. Lab or other diagnostic results;
iii. Any other information that would suggest a diagnosis.
5. Electronic – Messages will be received from patients through MyChart and questions may be
answered through MyChart by the clinic staff.
6. Documentation will be made in the electronic medical record (EMR).
a. Within the EMR, staff can access an electronic copy of Telephone Triage protocols for
Nurses by Julie K. Briggs, RN, BSN, MHA. Hard copies of this book are also available for
reference in some clinics. Pediatrics staff has access to hard copies of Pediatric
Telephone Protocols by Barton d. Schmitt, MD, FAAP.
b. RNs are encouraged to use Health Link smart phrases to aid in efficient documentation
such as .natriagecall for the basic call information, and .natriageclose to document that
the callers needs were met to their satisfaction.
7. Follow additional clinic-specific policies if applicable.
8. A Health Facts for You #7637 - Ambulatory Telephone Nurse Triage at UWHC is a tool that can be
used to help patients understand and use telephone nurse triage.
Greenberg, M.E. (2009). A comprehensive model of the process of telephone nursing. Journal of Advanced
Nursing, 65(12), 2621-2629
Health Facts for You #7637 - Ambulatory Telephone Nurse Triage at UWHC
Hospital Administrative Policy 6.24 – Communication with Patients Outside of the Clinical Setting
Position of the Board of Nursing on Telephone Triage, State of Wisconsin Board of Nursing, 4/11/2013
Purc-Stephenson, R.J. & Thrasher, C. (2010) Nurses’ experiences with telephone triage and advice: a meta-
ethnography. Journal of Advanced Nursing, 66(3), 482-494
Rutenberg, C., and Greenberg, M.E. (2012). The art and science of telephone triage: how to practice nursing over
the phone, Anthony J. Janetti, Pittman, NJ.
Telehealth Nursing Practice Administration and Practice Standards, 20115
Edition, American Academy of
Ambulatory Care Nursing
UWH Form #1280490 - Authorization for Verbal Communication and/or to Leave Voice mail Messages
UWHC Administrative Policy 6.24 - Communication with Patients Outside the Clinical Setting
IV. REVIEWED AND APPROVED BY
Nursing Education Specialist, Ambulatory Clinics
Ambulatory Policy and Procedure Committee
Karen Leimkuehler, RN, MS, Clinic Operations Director