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Encounter ID
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Your Name
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Chief Complaint
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Was the patient triaged?
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Does this patient require follow up?
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Schmitt-Thompson Protocol(s) Selected
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Name of Triage Protocol with Results
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Onset of Symptoms
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History of Current Illness (exacerbating factors, alleviating factors, pain scale, all relevant information)
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The patient was directed to which level of care?
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Was 911 Activated?
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Was the patient agreeable to the plan of care?
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Was video or phone used? (select all that apply)
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Education Discussed
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Was Nurse Advice given to patient?
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Current Symptoms
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Disease Management
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Health Promotion
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OTC Treatment
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OTC Medications
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Prescription Medications
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Level of Understanding
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