QUICK TRIAGE

a. Visit Reason
b. Significant Health History
c. Pain Assessment
d. ESI
e. Infectious Disease screening *
f. MOPH Injury registry *

FULL TRIAGE

a. Problem being addressed

b. Diagnosis – G6PD
c. Allergies
d. Vital signs
a. HT and weight
b. Sepsis
e. Pain assessment
f. Fall Screening
g. System Focused Assessment
h. Learning Needs Assessment

DOCUMENT HOME MEDICATION

a. Medication History with green check mark

MINOR INJURY CLINIC

a. Quick Triage ( Same Critteria)

b. Vital Signs and Weight
c. Document Home Medication
d. MOPH
e. ED Note Nursing : Subject: Minor Injury Clinic(MIC) + Shift
a. Attending Physician/NP
b. Reason for visit
c. Assessment
d. Disposition

f. System Focused assessment

a. IView: Pediatric System Assessment
i. Pain assessment
ii. Neurological
iii. Safety Check
iv. Pulses
v. Neurovascular Check
vi. Neuromuscular/extremities – if applicable

b. Pediatric Skin ADL

i. Integumentary
ii. Incision/wound
iii. AdHoc: Neurovascular assessment upper and lower extremities
Urgent Care and Fast Track

a. Vital signs
a. 30 mins – 1 hour post full triage
b. ESI 4 and 5 – Every 2 – 4 hours
a. Prior and Post any procedure and patient intervention with expected
changes in Vital signs
b. Neurological Assessment (IView)
c. Pain assessment (IView)
a. Initial Evaluation – if new onset of pain then to complete pain assessment in
detail plus pain intervention if applicable
b. Reevaluation – post full triage then every 1 hour
c. Before and after any intervention
d. Safety check – initial, before and after any intervention, prior discharge
e. Fall assessment – as per policy
a. if high risk should b every 1 hour
b. if low risk should be every shift
c. prior transfer
d. post procedure
e. changes is PEWS or Level of consciousness
f. After patient fall
f. Transfer of Care – any patient that will be transferred to another
unit/intradepartmental/other facilities *if applicable
g. Health Education – Iview > Patient and Family Education
a. Facility orientation – General Education > Symptomatology
b. Isolation precaution and unit procedure for isolation – if applicable : General
Education > Infection
c. Hand hygiene - General Education > Infection
d. Pre and Post Procedure Education – especially for patient for procedural
sedation
h. ED Note Nursing : Subject: UCC/Fast Track room number + Shift
a. Initial assessment – Patient condition when received and time patient
received in the unit
b. Health care providers who managed the child and time seen
c. Plan of care and interventions done
d. Special endorsement: e.g. LAMA, DAMA, complain on plan of care/hospital
stay/waiting to be seen, other concern pertaining to patient safety and
welfare.
e. Disposition to include patient condition prior discharge/transfer
Procedural Sedation

a. Patient Handover – IView > Pediatric System Assessment > Transfer of care
a. Handover by Primary Nurse to Procedural Sedation Nurse (Prior procedure)
b. Handover by Procedural Sedation Nurse to Primary Nurse (to be completed Post
Procedure if met with the acceptable Aldrete Score)
b. Vital Signs
a. Primary Nurse – to complete prior transfer
b. Procedural Sedation Nurse (IView > Moderate Sedation)
i. Pre Procedure
ii. 5 Minutes interval throughout the procedure
iii. Post procedure
iv. Prior Transfer to patient assigned location
v. Aldrete Score – Prior transfer and Prior Discharge to the Unit
c. Fall assessment
c. Procedural Sedation Checklist (Adhoc) – Procedural Sedation Nurse
a. Procedural Sedation Room: To be completed before administering sedation
b. Pre Discharge Checklist
d. Physician Orders for sedation and medication – Reviewed by the Procedural Sedation Nurse
in the nurse review column (can be verified on the order MPage if reviewed by the nurse)
e. Medications
a. Signed and with witness
b. Documented in a timely manner
f. ED Note Nursing : Subject: Procedural Sedation: Procedure to be done + Procedure room
number + Shift
a. Initial assessment – Patient condition when received
b. Health care providers who managed the child and time seen
c. Outcome of the procedure
i. Patient condition prior and post procedure
ii. Any problem/difficulties assessed during the procedure
iii. Dressing done
iv. Effects of medications
v. Follow up instructions
vi. Special endorsement: e.g. LAMA, DAMA, complain on plan of care/hospital
stay/waiting to be seen, other concern pertaining to patient safety and
welfare.
d. Patient condition prior transfer to patient assigned location
g. Patient and Family Education – IView – if education was given by the procedural sedation
nurse
a. Pre and Post Procedure Education
Treatment Room

a. Vital signs
a. Within 30 mins to 1 hour post full triage
b. As per ESI Level
i. 1 – Every 10 mins
ii. 2 – 15 – 20 mins
iii. 3 – every 1 hour
iv. 4 and 5 – every 2 – 4 hours
c. PEWS
d. Height and weight
e. Prior and Post any procedure and patient intervention with expected
changes in Vital signs
b. Neurological Assessment (IView)
c. Pain assessment (IView)
a. Initial Evaluation – if new onset of pain then to complete pain assessment in
detail plus pain intervention if applicable
b. Reevaluation – if with documented pain post full triage to complete pain in
detail and pain intervention (if applicable) then reassessment every 1 hour
c. Before and after any intervention
d. Comprehensive assessment within 2 hours of patient admission to unit
a. System focused Assessment
b. Fall assessment – as per policy
i. if high risk should b every 1 hour
ii. if low risk should be every shift
iii. prior transfer
iv. post procedure
v. changes is PEWS or Level of consciousness
vi. After patient fall
c. Safety check – initial, before and after any intervention or procedure and
prior discharge
d. Devices and procedures (Every 1 hour) *currently available
i. Intravenous line assessment
ii. Central Line assessment
iii. Chest Tubes
e. Physician Orders – Reviewed by the primary nurse in the nurse review column (can
be verified on the order MPage if reviewed by the nurse)
f. Medications
a. Signed and with witness
b. Documented in a timely manner
g. Intake and output
h. Initiate IPOC – if applicable
i. Transfer of Care – any patient that will be transferred to another
unit/intradepartmental/other facilities *if applicable
j. Health Education – Iview > Patient and Family Education
a. Facility orientation – General Education > Symptomatology
b. Isolation precaution and unit procedure for isolation – if applicable : General
Education > Infection
 c. Hand hygiene - General Education > Infection
d. Pre and Post Procedure Education – applicable for procedural sedation
k. ED Note Nursing : Subject: Treatment: area (1 or 2) + Patient room number + Shift
a. Initial assessment – Patient condition when received and time patient came
to the unit
b. Health care providers who managed the child and time seen
c. Plan of care during stay in ED and interventions done (Patient journey)
d. Special endorsement: e.g. LAMA, DAMA, complain on plan of care/hospital
stay/waiting to be seen, other concern pertaining to patient safety and
welfare.
e. Disposition to include patient condition prior discharge/transfer
Observation Room

a. Vital signs
i. Within 30 mins to 1 hour post-handover
ii. As per ESI Level
i. 1 – Every 10 mins
ii. 2 – 15 – 20 mins
iii. 3 – every 1 hour
iv. 4 and 5 – every 2 – 4 hours
iii. PEWS
iv. Height and weight
v. Prior and Post any procedure and patient intervention with expected
changes in Vital signs
b. Neurological Assessment (IView)
c. Pain assessment (IView)
i. Initial Evaluation – if new onset of pain then to complete pain assessment in
detail plus pain intervention if applicable
ii. Reevaluation – if with documented pain post full triage to complete pain in
detail and pain intervention (if applicable) then reassessment every 1 hour
iii. Before and after any intervention
d. Comprehensive assessment within 2 hours of patient admission to unit
i. System focused Assessment
ii. Fall assessment – as per policy
i. If high risk should b every 1 hour
ii. If low risk should be every shift
iii. Prior transfer
iv. Post procedure
v. Changes is PEWS or Level of consciousness
vi. After patient fall
iii. Safety check – initial, before and after any intervention or procedure and
prior discharge
iv. Devices and procedures (Every 1 hour) *currently available
i. Intravenous line assessment
ii. Central Line assessment
iii. Chest Tubes
e. Physician Orders – Reviewed by the primary nurse in the nurse review column (can
be verified on the order MPage if reviewed by the nurse)
f. Medications
i. Signed and with witness
ii. Documented in a timely manner
g. Intake and output
h. Initiate IPOC and document if goals are met and not met
i. Transfer of Care – any patient that will be transferred to another
unit/intradepartmental/other facilities *if applicable
j. Health Education – IView > Patient and Family Education
i. Facility orientation – General Education > Symptomatology
ii. Isolation precaution and unit procedure for isolation – if applicable : General
Education > Infection
 iii. Hand hygiene - General Education > Infection
iv. Fall education
v. Pain education – if patient states pain
vi. Safety education
i. Plan of care discussed with pt/family
k. ED Note Nursing : Subject: Observation: area (1 or 2) + Patient room number + Shift
i. Initial assessment – Patient condition when received and time patient came
to the unit
ii. Health care providers who managed the child and time seen
iii. Plan of care during stay in ED and interventions done (Patient Journey)
iv. Special endorsement: e.g. LAMA, DAMA, complain on plan of care/hospital
stay/waiting to be seen, other concern pertaining to patient safety and
welfare.
v. Disposition to include patient condition prior discharge/transfer
Resuscitation

i. QUICK TRIAGE
a. Visit Reason
b. To identify as Tier 1 or Tier 2 – endorsed to Resuscitation team
c. Significant Health History
d. Pain Assessment
e. ESI
f. For trauma – significant events to handover with the resus team
i. Time trauma was activated
ii. Transferred from (which location)
iii. Mechanism of injury
iv. History of the event
v. Estimated time of arrival
vi. ATMISTER form to handover to the resus team
g. Infectious Disease screening *
h. MOPH Injury registry *
ii. Resuscitation Team Documentation (Medical/Trauma)
1. Medication Nurse
a. Weight measured and weight Dosing – IView > ED Pediatric Condensed
View > Measurements
b. Allergies – Mpage
2. Documentation Nurse
a. Vital signs – to be completed retrospectively
i. Initial
ii. Prior transfer to another location
iii. PEWS
b. Problems and Diagnosis (MPage) – to complete the reason for visit only
c. Safety check
d. Fall risk assessment
e. Document Home Medication - to be completed retrospectively.
f. Medications Given - to be completed retrospectively
i. Communication type: Verbal/Readback Validated
ii. Orders needs to be co-signed by the ordering physician
iii. Signed by the medication nurse and witnessed by the ED
Pharmacist on duty retrospectively
g. Laboratory investigation – must be initiated in the system once ordered
verbally by the physician to be able to print out specimen labels and scan
barcodes for collection prior sending specimen to lab. This can be initiated
by task 2 nurse.
i. Communication type: Verbal/Readback Validated
ii. Orders needs to be co-signed by the ordering physician done
retrospectively
iii. For Massive transfusion coordinator – to initiate the MTC
protocol in the system
h. Diagnostic imaging
i. Procedures – ED Lines and Devices (IView)
i. Intravenous access (IView)
 ii. Urinary catheterization (ED Treatment and Procedures icon on
the tracking board)
iii. Chest tube insertion (IView)
iv. Central Line (IView)
j. Intake and Output – if applicable
k. Intra hospital Transfer (AdHoc) – here it indicates the patient condition
prior transfer
l. Transfer of Care – any patient that will be transferred to another
unit/intradepartmental/other facilities
m. ED Resuscitation Downtime form fully accomplished, scanned and
uploaded in the system.
Discharge to Home

To complete 30 minutes prior discharge

a. Vital signs
b. PEWS (IView)
c. Neurological Assessment (IView)
d. Pain assessment (IView)
e. Safety Check (IView)
f. Patient Education (Discharge Planning Education) – for your kind review
a. Understands Discharge Plan
b. Follow up services/care/appointment – this is applicable to patient with
follow up consultation to any Sidra Medicine Facilities
c. Home heath
d. Information sources at discharge – patient education leaflets
g. Discharge Summary (AdHoc)
h. Discharge Disposition – Discharge to home or selfcare
i. ED Patient Summary – should capture below criteria
a. Discharge Medical Diagnosis
b. Medications given in the ED
c. Prescribed Medications
d. Patient Education Information
e. Follow up – if applicable

Discharge to In Patient

To complete 30 minutes prior discharge

a. Vital signs
b. PEWS (IView)
c. Neurological Assessment (IView)
d. Pain assessment (IView)
e. Safety Check (IView)
f. Transfer of Care (IView)
g. Intra hospital Transfer (AdHoc)
h. ED Admit – Disposition: Discharge/Transfer to in patient
i. SBAR Form completed and uploaded
Discharge to Other HC Facilities

To complete 30 minutes prior discharge

a. Vital signs
b. PEWS (IView)
c. Neurological Assessment (IView)
d. Pain assessment (IView)
e. Safety Check (IView)
f. Transfer of Care - IView > Pediatric System Assessment *if applicable
g. Interfacility transfer (AdHoc)
h. Discharge Disposition – Discharge/Transfer to other Facility
i. ED Patient Summary – should capture below criteria
a. Discharge Medical Diagnosis
b. Medications given in the ED
c. Prescribed Medications

Patient Refuse to Pay

I. Quick Triage
a. Visit Reason
b. Significant Health History
c. Pain Assessment
d. ESI
e. Infectious Disease screening *
f. MOPH Injury registry *

*if patient refused to go through Full triage for Vital signs

i. ED Note Nursing : Subject: Quick Triage + Patient Refuse to Pay + Shift

1. Initial assessment – Patient condition when received and time
patient came to the unit
2. Reason for refusal for ED management
3. Patient condition prior leaving the ED Unit
ii. Disposition: Patient Seeks Treatment Elsewhere done as a triage out discharge
II. Full Triage
a. ED Triage Assessment form completed - If ESI is still the same inform patient care
access.
* If patient still refuses to pay
a. ED Note Nursing : Subject: Full Triage + Patient Refuse to Pay + Shift
1. Initial assessment – Patient condition when received and time
patient came to the unit
2. Reason for refusal for ED management
3. Patient condition prior leaving the ED Unit
b. Disposition: Patient Seeks Treatment Elsewhere done in discharge process
Left without being seen
a. ED Note Nursing : Subject: Full Triage + Patient Refuse to Pay + Shift
i. Initial assessment – Patient condition when received and time patient came
to the unit
ii. Reason for refusal for ED management
iii. Patient condition prior leaving the ED Unit
iv. Disposition: Left without being seen done in discharge process