Nurse Triage Protocols & Guidelines, Clinical Training Content, System Components

FREE Clinical Triage Resources

  • 3 VOLUME, AGE-BASED, 5-LEVEL NURSE TRIAGE PROTOCOLS & GUIDELINES

  • 9 UPDATED GUIDELINE COMPONENTS AND EXEMPLARS

  • 6 CLINICAL TRIAGE TRAINING ARTICLES

  • 20 MALPRACTICE CASE STUDIES (AUDIOLINKS)

  • 4 SLIDE DECKS OF TRIAGE TOPICS

  • FIRST FOUNDATIONAL “HOW TO” TRIAGE TRAINING MANUAL

  • ALL MATERIALS ARE FREE AND MAY BE DOWNLOADED. SOME MATERIALS ARE STILL IN PROCESS. PLEASE STAY TUNE

Nurse Triage Protocols & Guidelines

  1. Adult, Geriatric & Womens’ Health, Triage Protocols & Guidelines (2017) (PDF-215.8 MB)

  2. School Age Children, Age Six to 18 Years, Triage Protocols. & Guidelines (2017) (PDF-62.7 MB)

  3. Infants and Children Age Birth to Six Years, Triage Protocols & Guidelines. (2005) (PDF-36 MB)

Updated Triage System Components

  1. Workflow Process (2025) Nurse triage requires estimating and classifying symptom urgency. Nurse Triage Process Work Flow clearly illustrates Structure, Process and Outcome of this task -- 5-level triage. Deceivingly simple in appearance, it represents how the nursing process (assessment, working diagnosis, plan, evaluation) applies to the task of triage. It also bolsters informed consent, designating when, where and why a patient should be further evaluated, as appropriate. (PDF-2.3 MB)

  2.  Triage Documentation Form (2025-2026) An early, foundational documentation form faithfully represents the nursing process –modified for triage. The missing fourth step–evaluation (outcome), and would require modified HIPAA regulations. EMR/EHR’s prospective role: synthesizing patient context, that of risk level, plus past and current medical history (PDF-692 KB)

  3. QA AUDIT (2025-2026) Nurse triage performance improvement review. Quality Assurance of Triage Process, Communication, Documentation and Continuity (PDF-147 KB)

  4.  Triage Rules of Thumb (Heuristics) (2025-2026) Researchers found that nurses use Rules of Thumb to perform Triage (Lephrohon, Patel 1995) (PDF-182 KB)

  5.  Triage Job -Qualifications, -Description & -Competencies (2025-2026) (PDF-781 KB)

  6. Care for Caregivers (2025):  Stress Reduction, Self Care, Job Satisfaction for a High Stress Job (2025) (PDF-66 KB)

  7. Triage-Specific Phone Tree (2025) Avoid “Triage Call Volume Overload” (PDF-35 KB)

  8. Patient Brochure: Triage Services (2025) “How to Help the Triage Nurse Help You” (PDF-72 KB)

  9. Universal Guideline (2025-2026) “Uber Triage Checklist: (Pending)

    Copyright 1993 -2026 Sheila Quilter Wheeler, TeleTriage Systems Publishers.  All Rights Reserved

    Clinical Training Resources

  1. Essentials for Expert Nurse Triage. Part One. (2025) Nurse Triage “How To” Course (PDF-505KB) 

  2. Triage Risk Management 3 (2020-2026) (Pending) Research, Standards, Case studies(PDF-954KB)  

  3. Triage Guideline Competency (2017)  First User’s Guide for Nurse Triage Guidelines (PDF-6.6MB) 

  4.  Safety of Clinicians and Non-Clinicians Performing Triage. (2015) Narrative review of clinicians” and non-clinicians’ triage practice and safety. Journal of Telemedicine and Telecare: (PDF-186KB)

  5. Triage Risk Management 1 (2005) Triage trends, risks, controversies & case studies. (PDF-1MB)

  6. Triage Risk Management 2  (2006) Experts discuss nurse triage risks & solutions. (PDF-800KB)

  7.  Triage Articles & Research (2000-2020) Archival Triage topics by Wheeler. (PDF-28.2 MB)

    Malpractice Case Studies & Tutorials

  8. 10 + Case Studies (1993) (Delmar-Thompson), Re-enacted Adult & Pediatric Malpractice Cases (MP3-11.8 MB)

  9. 10 + Case Studies (2009) (McGraw Hill) Re-enacted Adult & Pediatric Malpractice Cases (MP3-6.3 MB)

    Slide Decks of Triage Topics

  10. A set of four slide decks provide an overview of key issues in the emerging subspecialty of nurse triage. Collectively, the slides address current risk management issues, system error, common practice error leading to malpractice, nurse triage standards and clinical training for triage.

  11. Nurse Triage: Creating a Culture of Safety (2020) Risk Management (PDF-372 KB)

  12. Triage Protocols for High Risk Populations (2019) Protocol Design, Bhopal India (PDF-241 KB)

  13. To Err is Human, To Delay is Deadly (2012 - 2025) Risk Management. case studies (PDF-372 KB)

  14. Essentials for Expert Practice (2016 - 2025) (Pending) Slides for updated “How To” article

  15. Foundational: Nurse Triage Training Manual

  16. Telephone Triage: Theory, Practice & Protocol  (1993) First “How to” for Nurse Triage. (PDF-62.5 MB)

    Nurse Triage Protocols & Guidelines

  17. Adult, Geriatric & Womens’ Health, Triage Protocols & Guidelines (2017) (PDF-215.8 MB)

  18. School Age Children, Age Six to 18 Years, Triage Protocols. & Guidelines (2017) (PDF-62.7 MB)

  19. Infants and Children Age Birth to Six Years, Triage Protocols & Guidelines. (2005) (PDF-36 MB)

    Copyright 1993 -2026 Sheila Quilter Wheeler, TeleTriage Systems Publishers.  All Rights Reserved

TeleTriage Systems Copyright Statement

Copyright 1993 -2026 Sheila Quilter Wheeler, TeleTriage Systems Publishers.  All Rights Reserved.  All materials are protected by copyright.  No part of it may be reproduced, stored in a retrieval system, or transmitted, in any form, or by any means – electronic, mechanical, photocopy, recording or otherwise – without prior written permission of Sheila Wheeler, except for brief quotations embodied in critical articles and reviews. For problems receiving free materials, or permissions, contact Ms. Wheeler by phone 415 453 8382

Nurse Triage Terminology for an Evolving Specialty

Please Note: Terminology related to the emerging field of pre-hospital triage is still evolving. Currently, nurse triage appears to be the broadest and most inclusive term, encompassing remote settings (telephone triage, clinical call centers, pre-hospital, virtual and/or telehealth) and on-site triage settings (ED, Urgent Care, other). Thus, terms like advice nurse, telephone nurse and even telephone triage now seem less helpful or useful.

TeleTriage Systems’ Component Exemplars. In addition, articles — both clinical and commentary, and foundational to current — describe its early days and subspecialty growth.

The Articles address risk reduction strategies, clinician qualifications, and guideline limitations as well as technology’s impact on triage safety, along with inadequacies in documentation, communication and disposition clarity standards.

As the field evolved from embryonic to infancy to emerging, so did the terminology, from nurse advice, telephone triage and remote triage to virtual triage, telelealth andclinical call center. Correspondingly, Wheeler’s unique system terminology adapted the nursing process to a nurse triage process, decision-making to decision support, protocols to guidelines, and even Wheeler’s unique assessment acronyms have evolved as required by industry changes.

The following resources represent a four-decade foundational electronic “paper trail” — evidence of Ms. Wheeler’s attention to standards continuity while developing a complete system .

Collectively, Ms. Wheeler addresses potential solutions to current risk management issues related to malpractice cases — system error, recurrent practice error, inadequate nurse triage standards and clinical training. Please stay tuned.

Rather Buy Bound Nurse Triage Protocols/Guidelines? Purchase the complete set for under $50.

Free audio links for 20+ malpractice case studies with tutorials.