Characterization of the hospital triage record in two hospitals in the metropolitan area of Medellin, Colombia

Abstract

Introduction: triage is a strategy to classify patients and optimize available resources. The objective of this study was to characterize the information recorded in the clinical history of emergency triage in two hospital institutions. Materials and methods: a cross-sectional descriptive study was carried out in two public institutions in the metropolitan area of Medellin, Colombia. A stratified sampling was carried out in which 687 records of patients treated in the emergency services in the month of August in 2019 were selected. Patient information was collected, such as gender, age, other demographic variables and the result of their triage classification. From the hospital, its level of complexity was recorded. Results: 64.2% of the records repeat some information, common elements of a general clinical history are recorded, such as the reason for consultation in 65.4% of cases, current illness in 75.1%, medical history in 65.4% and physical examination in 57.6%. These last two were characterized by being exhaustive and not very relevant. 14.4 of the triages included the diagnosis, 13.4% a summary and 18.9% an intervention plan. 31.2% of the triages were classification II, 37.4% had between 51-100 words, and 77.5% were records of patients who belonged to the subsidized health regime. Conclusion: the reviewed triage medical records contain information similar to that of a general medical record, with some exceptions. Additionally, the triage classification seems to have some relationship with the number of words in the document, as well as the patient's social security regime.