Notes

The Notes section of Triage Assessment contains several tabs where you may enter supplementary notes, see Note Tab Descriptions table below for important details about each tab.

To Enter Notes

Click on the tab you wish to document in.

Important: You may be able to view and/or copy Notes from previous ED visits, see Previous Visits.
Enter Notes as clinically appropriate, see Note Tab Descriptions table below.

Note Tab Descriptions

Tab Name	Description
EMS	Reports received from Paramedic(s) or other pre-hospital providers who arrived with the patient can be entered here. If applicable, EMS Arrival and Off Load Information can be entered. This is a free text field, information is saved as you type. Modify existing notes as needed. Note: The EMS tab will only appear if the patient mode of arrival was indicated as EMS during Patient Presentation (Pretriage).
Subj	Subjective: the patient’s story or background information not included in the Patient’s Stated Complaint field may be entered here (e.g. a patient states they were standing on a tall step ladder and fell). This is a free text field, information is saved as you type. Modify existing notes as needed. Note: The Subj tab displays a Recommended Assessment dialog box for some CEDIS complaints (e.g., Insomnia). Respond (i.e., Cancel, Add), if you choose to Add information, you must click the Add to Subjective Notes button to save your response.
Obj	Objective: nurse’s assessment notes not included in the Nurse Assessed Complaint field may be entered here. (e.g. a nurse observes blue discoloration across patient’s abdomen). This is a free text field, information is saved as you type. Modify existing notes as needed.
TMT	Treatments and Interventions initiated at triage may be entered here Enter text (suggestions appear as your type) or select from a dropdown list of predefined terms. You may edit, reorder or remove notes, see Tips to modify Tmt/Int, Med Hist, Meds and Allergies Notes.
Med Hist	Medical History: Relevant medical history may be entered here, including No Significant Medical History. Select from the list, or enter free text, and click Enter. Enter text (suggestions appear as your type) or select from a dropdown list of predefined terms. You may edit, reorder or remove notes, see Tips to modify Tmt/Int, Med Hist, Meds and Allergies Notes.
Meds	Medications: Patient medications may be entered here, including No Reported Medications at Triage. Select from the list, or enter free text, and click Enter. Enter text (suggestions appear as your type) or select from a dropdown list of predefined terms. You may edit, reorder or remove notes, see Tips to modify Tmt/Int, Med Hist, Meds and Allergies Notes.
Allergies	Document patient allergies. Enter text (suggestions appear as your type) or select from a dropdown list of predefined terms. If a patient has no known allergies, the nurse may select No Known Allergies (NKA) from the list and click Enter. You may edit, reorder or remove notes, see Tips to modify Tmt/Int, Med Hist, Meds and Allergies Notes.

Note: If allergies are documented, allergy alerts appear, i.e.,:

Allergyappears next to the patient’s name on the Triage Assessment screen.

An Allergy icon A appear appears (i.e., Triaged Patients Queue, Patient Summary area)

Tips to Modify Tmt/Int, Med Hist, Meds and Allergies Notes

Action	Instructions
Selection methods list	Use the arrow keys on your keyboard to highlight an item, then press Enter to select it. To select multiple items press and hold Ctrl on your keyboard, then click on your chosen items. Click anywhere outside of the list to close it.
Edit a free text or predefined item (by mouse only)	Note: only the last item in the list can be edited. You can reorder items to edit as needed. Click or Tab into the field With the last item selected, press Backspace, then edit the item as needed Press Enter to save your changes
Reorder selected items (by mouse only)	Click and hold the 3 horizontal bars on the left of the listed item Drag the item to the desired position in the list
Remove selected items	By mouse Click on the X on the right of the listed item If list of predefined items is open, click on a selected item again to deselect it By keyboard For the last item in the list: Press Backspace to delete the item For all other items: From within the Notes field, press Enter to open the lis> Use the arrow keys to navigate to the item you wish to remove (highlighted in grey) Press and hold Ctrl, then press Spacebar to remove the selected item