Triage Nursing Template

Spoken with: Mrs. Jane Doe, the patient's daughter.
Introduced self, role & reason for call: I identified myself as Nurse Emily, a community nurse, and explained that I was reaching out to discuss Mr. John Doe's recent health issues and to offer guidance on his care.
S: Mr. John Doe, 78 years old, has been experiencing increased shortness of breath and fatigue over the past week. His daughter is worried about his ability to handle daily activities.
B: Mr. Doe has a medical history of chronic obstructive pulmonary disease (COPD) and hypertension. He was recently released from the hospital after a COPD exacerbation.
A: Upon evaluation, Mr. Doe shows signs of mild respiratory distress with noticeable wheezing. His oxygen saturation is 92% on room air.
R: Advised Mrs. Doe to ensure Mr. Doe consistently uses his prescribed inhalers and to keep track of his oxygen levels. Suggested scheduling a follow-up visit with his GP within the next week.
Worsening advice given: Instructed Mrs. Doe to seek immediate medical care if Mr. Doe's breathing deteriorates or if he experiences chest pain.
OTHER RELEVANT INFO: Mr. Doe has a history of not adhering to his medication regimen, which should be addressed in future consultations.
Property access: No known obstacles to accessing the property.
Animals: There is a small dog at the property, which is friendly and poses no threat.
Social: Mr. Doe resides with his daughter, who is his primary caregiver. They have a supportive family network nearby.
BMI / build: Mr. Doe has a BMI of 28, indicating he is overweight, which may contribute to his respiratory problems.
Patient cognition: Mr. Doe is alert and oriented, with no cognitive impairments observed.
Other risks: Environmental risk includes exposure to secondhand smoke, as his daughter smokes inside the home.