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Telephone Triage Task Delegation & Misrepresentation: Risk Management

Delegating Tasks to Unqualified Staff

I am often asked about a recommended “list of key symptoms for clerical staff to use to pre-triage patients”. I do not have such a list, nor do I recommend this risky policy. If your facility implements such a task delegation policy, I recommend that nurses meet with the hospital counsel in regard to this matter, as well as getting the policy in writing.

While symptoms such as chest pain, difficulty breathing and severe pain are obviously urgent symptoms, to date, there is no research evidence that any special list of other key symptoms enables non-clinicians to safely “pre-triage” symptoms. While many facilities currently allow this in order to cut costs, it is risky, based on my experience as an expert witness, and especially with pediatric populations.  It is likely that this practice — common in physician’s offices — has spread to ambulatory care settings-at-large, and may be related to confusion over who (physicians, corporations or nurses) is legally authorized to delegate certain tasks to unqualified staff.

There are several reasons I do not recommend this policy.

  • It is difficult to assess symptom urgency by phone, even for qualified clinical staff who have performed thorough assessments.
  • No “Top Ten” symptom list can adequately cover the range of presentations of urgent symptoms. For example, symptom presentation may be atypical, silent or novel.
  • Laypersons often miscommunicate, deny symptoms, or self-diagnose and relay erroneous information to the clerical staff. Some patients label symptoms as ” bad case of the flu”, when symptoms may represent early signs of sepsis.

Using clerical staff in this way may be cost-effective, but may result in delay of care, patient harm and malpractice lawsuits.  Rather than using clerical staff to pre-triage symptoms, I suggest the following:

  • All clinical calls be assessed first by clinicians, and then transferred to the appointment staff for the clinically- recommended appointment.
  • Use a voice message system to direct callers to leave messages on separate lines for:
    • Lab, x-ray results (transferred to appropriate clinician)
    • Pharmacy requests
    • Class registration
    • Non-clinical messages to physicians
    • Directions, hours
  • All the following calls may go directly to clerical staff:
    • Routine annual physical appointment scheduling
    • Routine follow up appointment scheduling
    • Calls routed to them by clinicians for subsequent appointments


Finally, titles for non-clinicians should be clearly non-medical, such as “Appointment clerk or scheduler”, “Office clerk” or “Administrative Assistant”. Ambiguous titles such as Medical Service Representative, or medical assistant may mislead callers into thinking they are speaking with clinicians. This can lead to a charge of misrepresentation, if no one corrects that impression.

Written by Sheila Wheeler (15 Posts)

SHEILA WHEELER, RN, MS, is acknowledged as an international expert in the field of telephone triage. She has practiced nursing for over 30 years, primarily in critical care, emergency department and clinic settings. An accomplished writer, educator, researcher and consultant, Ms. Wheeler is currently President of TeleTriage Systems in San Anselmo, California.