Telephone Triage/Advice Note (Pediatrics)

Date/Time of Call: [date; time received; time ended or duration]

Patient: [name; DOB; MRN]

Caller: [name; relationship to patient; callback number]

Clinician: [name; credentials; role]

Interpreter: [language; interpreter ID] (Only include if an interpreter was used)

Patient Location: [city, state] (Only include if after-hours or if symptoms may require EMS referral)

Reason for Call

[Primary concern and why calling now] (Use a direct quote from the caller if it clearly captures the concern. If multiple concerns are raised, identify the primary concern driving triage and briefly note secondary concerns or that they will be addressed separately.)

Reported Symptoms and History

Per [caller identity]: [Age and baseline health status]. [Symptom timeline, onset, and progression]. [Severity indicators including behavior, activity level, consolability, and intake]. [Home measurements with method and units]. [Pertinent positives and negatives influencing triage]. [Relevant medical history, allergies, and medications if they affect triage or advice]. [Interventions tried and response].

Safety screen: [Red-flag findings assessed relevant to the presenting concern, noting presence or absence] (Document age-appropriate red flags such as work of breathing, hydration status, mental status, rash characteristics, or fever parameters. If a critical domain cannot be assessed, document "unable to assess" and note that disposition was adjusted conservatively. If required information is missing, document "unable to obtain.")

Assessment

[Clinical impression based on reported information] (Use qualifying language appropriate for telephone encounters, e.g., "symptoms consistent with..." Acknowledge limitation that no physical examination was performed when relevant.)

Plan

Advice: [Home care guidance and monitoring instructions]. [Medication recommendations with product, dose, route, frequency, and weight used for calculation] (If weight is unknown or unreliable, note this and advise following package labeling or scheduling a visit for weight-based dosing.)

Disposition: [home care with monitoring / same-day office visit / next-day office visit / urgent care / emergency department / call 911]; [timeframe]; [brief rationale linking disposition to symptoms and safety screen findings].

Return Precautions:

• [Warning sign and action to take]
• [Warning sign and action to take]
• [Timeframe for reassessment if no improvement and action to take]

[Caller verbalized understanding of instructions] (If caller disagrees or cannot comply, document discussion and alternative arrangements.)

Protocol used: [protocol name; disposition category] (Only include if a decision-support tool was used)

Consultation: [clinician consulted; time; guidance provided] (Only include if consultation occurred)

Follow-up: [callback timing or message routed to primary care team] (Only include if arranged)