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Adult & Pediatric Telephone Triage Guideline Table of Contents


Adult and Pediatric Telephone Triage Guidelines must be fast and easy to use.  Because patients often present symptoms by site, titles are typically organized by anatomical site (and alphabetically) to facilitate locating the correct guideline!  Forty-plus guidelines cover over 1,500 possible conditions!

Abdomen Problem:

 1 (Upper & Generalized): Pain w or w/o Trauma;
2 (Lower): Pain w & w/o Trauma

Abuse: Sexual, Emotional, Physical, Financial

Back Problem (Upper & Lower):  Pain w or w/o Trauma

Behavioral Problems:

 Discipline: Temper Tantrums
Eating Problems: Food  Allergies
Elimination Problems: Bedwetting (Enuresis); Soiling
(Encopresis); Toilet Training
Sleeping Problems: Bedtime Resistance; Early Morning Riser
Night Terrors; Nightmares

Bites  (Skin Problem 1):

 1 (Human/Animal): Human; Cat; Dog; Bat; Horse; Squirrel;
Skunk; Raccoon;  Fox
2 Snake; Jellyfish; Sea Urchin; Stingray
3 Bee Stings, Yellow Jacket, Hornet, Wasp; Spiders; Scorpions;
Fleas; Ticks

Bowel Problem:

 1 Diarrhea (Severe/Moderate/Mild); Incontinence; Bloody  Stools
2 Constipation; Stool Color Change

Breast Problem:

 1 Female (Non Pregnant, Non Post Partum): Pain w or w/o Trauma;
Discharge; Lump; Lesions
2 Male: Pain w or w/o Trauma; Discharge; Lump; Lesions

Breast feeding Problem: Pain w or w/o Fever; Sore Nipples; Painful Breasts

Burn (Skin Problem 2):

 1 Thermal; Chemical; Electrical
2 Radiation (Sunburn)

Chest Pain:  Pressure/Pain; w or w/o Trauma

Cold Exposure: Hypothermia; Frostbite

Confusion:  Sudden; Chronic

Dizziness/Fainting:  W or w/o Trauma

Ear Problem:

 1 Pain w Trauma; FB; Hearing Loss; Ringing; Earlobe Trauma;
2 Pain w/o Trauma; Discharge; Congestion; Earlobe Swelling

Emotional Problem:

 1 Suicide in Progress; Threat; Ideation
2 Panic; Depression; Anxiety; Agitation; Aggression;
Withdrawal; Hallucination

Extremities Problem:

(Upper): Pain w or w/o Trauma; Swelling; Lacerations;
Fractures
(Lower): 1  Pain w Trauma; Swelling; Lacerations; Fractures
(Lower): 2  Pain w/o Trauma; Swelling; Weakness; Limp

Eye Problem:

 1 Pain w Trauma; Burn; FB; Vision Changes; Blood In
2  Pain w/o Trauma; Photophobia; Blood In; Discharge;
Swelling; Vision Changes

Face/Jaw:  Pain w or w/o Trauma; Swelling; Weakness

Fever:  High; Moderate; Mild

Head Problem:

 1 Pain; Laceration; Level of Consciousness Change w Trauma
2 Pain; Level of Consciousness Change w/o Trauma

Heat Exposure:  Heat Stroke; Heat Exhaustion; Heat Cramps

Joint Problem (Upper & Lower):

 Pain w or w/o Trauma; Swelling (Shoulder, Elbow, Wrist, Hip, Knee, Ankle, Foot); Limp

Lip/Mouth; Teeth/Gums; Tongue:  Pain w or w/o Trauma; Swelling; Laceration; Lesions

Neck Problem: Pain w or w/o Trauma; Swelling; Lump

Newborn Concerns:

Behavior; Care; Bathing; Circumcision; Cord; Dressing; Skin Eyes; Elimination: Meconium Stools; Breast fed; Bottle-Fed); Urine Output Feeding Questions; Genitals; Head: Bruises; Fontanelle; Lumps; Molding Mouth; Nose: Coughing; Nasal Discharge; Sneezing; Skin/Rashes: Cradle Cap; Diaper Rash; Eczema; Erythema Toxicum; Heat Rash, Milia; Newborn Acne; Skin/Birthmarks

Nose/Sinus Problem: Pain w or w/o Trauma; FB; Bleeding; Discharge; Congestion

Pain Assessment

Penile/Scrotal/Testicle Problem:  Trauma; FB; Pain; Discharge; Lumps; Lesions

Postpartum Problem:

 Leg Pain; Painful Urination; Incisional Pain; Fever; Bleeding; SOB; Diarrhea; N/V; Abd. Pain

Pregnancy Problems:

 1 Labor; Abdominal Pain; Vaginal Discharge; Vaginal Bleeding 2 Trauma; Headache; Chest Pain; Fetal Movement; N/V; Swelling; Burning on Urination; Itching

Rectal Problem:

 Pain w or w/o Trauma; FB; Bleeding; Itching; Discharge; Lesion

Respiratory Problem:

 1 Breathing Problem/Cough: Respiratory Distress; Choking; SOB; Stridor; w or w/o Trauma; 2 Throat: Choking; FB/Trauma; Pain; Burn: Chemical/Thermal

Seizures: W or w/o Trauma

Shock:  Distributive; Cardiogenic; Hypovolemic

Skin Problem:

 1 Bites: See Bites (Skin Problem 1) 2 Burn: See Burn (Skin Problem 2) 3 Discoloration: Bruise; Yellow; All Color Changes 4 Laceration/Wound: Amputations; Major and Minor Lacerations; Abrasions; Puncture Wounds 5 Lesion/Lump/Swelling: W or w/o Trauma 6 Rash: w or w/o Itching

Substance Abuse:   Drug/Alcohol, Other Substances

Urinary Problem: Pain w or w/o Trauma; Frequency; Urgency; Discharge; Change in Output/Color; Bloody Urine

Vaginal Bleeding (Non Pregnant):  Abnormal Bleeding: Painful, Irregular, Excessive;  Absence of Menses

Vaginal Problem (Non Pregnant): FB; Trauma; Discharge; Pain; Lesion; Itching; STD Exposure

Vomiting/Nausea: Excessive; Bloody/Fecal; Food/Toxin; Dehydration

Women’s Health: Menopause Issues and Concerns, FAQ; Birth Control Issues and Concerns, FAQ

Telephone Triage Guidelines or Protocols: Supplemental Information

Adult Telephone Triage Guidelines or Protocols (Age 18+)

Pediatric Telephone Triage Guidelines or Protocols (School Age: 6 -18 Years)

Pediatric Telephone Triage Guidelines or Protocols (Infant-Child: Birth to 6 Years)