What questions should pediatric office staff ask parents over the phone to safely triage their child's symptoms and determine the best course of action?

Pediatric Office Phone Triage Tip Sheet Using OPQRST

Critical Warning Signs - HANG UP AND CALL 911, THEN NOTIFY PHYSICIAN IMMEDIATELY

Staff must instruct parents to hang up and call 911 immediately if ANY of the following are present 1:

• Extremely labored breathing or respiratory distress (markedly raised respiratory rate, grunting, intercostal recession) 1
• Blue or pale color (cyanosis) 1
• Noisy breathing with severe distress (wheezing or stridor with respiratory compromise) 1
• Altered mental status, drowsiness, or decreased responsiveness 1
• Active seizure or prolonged/complicated seizure 1
• Uncontrolled bleeding 1
• Signs of septicemia (extreme pallor, hypotension, floppy infant) 1
• Vomiting after a head injury 1
• Severe dehydration with altered consciousness 1
• Parent appears extremely agitated or panicked about child's condition 1

OPQRST Framework for Information Gathering

O - ONSET

Questions to ask:

• When did the symptoms start? 2
• Did symptoms come on suddenly or gradually? 3
• What was the child doing when symptoms began? 3
• Has anything like this happened before? 3

P - PROVOCATION/PALLIATION

Questions to ask:

• What makes the symptoms better or worse? 3
• Have you tried any treatments at home? What happened? 4
• Is the child able to eat, drink, or sleep? 5
• Does anything specific trigger the symptoms? 3

Q - QUALITY

Questions to ask:

• Can you describe exactly what you're seeing/hearing? 1
• For fever: What is the actual temperature and how was it taken? 2
• For breathing problems: Is there any noise with breathing? 1
• For pain: Can the child describe what it feels like? 1
• For rash: What does it look like? Where is it located? 2

R - REGION/RADIATION

Questions to ask:

• Where exactly is the problem located? 3
• Does it spread anywhere else? 3
• Is it on one side or both sides? 3

S - SEVERITY

Questions to ask:

• On a scale of 1-10, how severe is this? 1
• Is the child acting normally otherwise? 5
• Can the child play, walk, or do usual activities? 1
• Is this getting worse, better, or staying the same? 2

T - TIME/TEMPORAL PATTERN

Questions to ask:

• How long has this been going on? 2
• Is it constant or does it come and go? 3
• Is it getting worse over time? 2

Additional Critical Screening Questions

Age-Specific Red Flags:

• For infants under 3 months: Any fever requires immediate physician consultation 6
• For all ages: Ask about chronic medical conditions (asthma, diabetes, heart disease, immune problems) 1

Associated Symptoms to Always Ask About:

• Fever: What is the actual temperature? 2
• Breathing: Any difficulty breathing, fast breathing, or chest pain? 1
• Hydration: When did child last urinate? How many wet diapers today? 5
• Eating/drinking: Is child able to keep fluids down? 1
• Behavior: Is child more sleepy than usual or difficult to wake? 1

Decision Tree for Disposition

ACTION 1: HANG UP, CALL 911, NOTIFY PHYSICIAN

Any critical warning sign listed above 1

ACTION 2: INTERRUPT PHYSICIAN IMMEDIATELY (Get physician out of room)

High-risk scenarios requiring immediate physician consultation 1:

• Infant under 3 months with any fever (>100.4°F/38°C) 6
• High fever >102.2°F (39°C) in any child with:
  • Severe earache 1
  • Vomiting >24 hours 1
  • Drowsiness or lethargy 1
  • Chronic medical condition (asthma, diabetes, heart disease, sickle cell) 1
• Breathing difficulties (not severe enough for 911 but concerning) 1
• Dehydration signs: No urine in 8+ hours, no tears when crying, sunken fontanelle 1
• Severe pain that child rates 8-10/10 or prevents normal activity 1
• Any head injury with vomiting, confusion, or severe headache 1
• Rash with fever and child appears ill 2
• Parent states "something is very wrong" even if can't specify why 1

ACTION 3: SCHEDULE APPOINTMENT (Same day or next available)

Moderate concerns requiring physician evaluation within 24 hours 4:

• Fever 100.4-102.2°F (38-39°C) in child >3 months without other concerning features 1
• Persistent vomiting or diarrhea (>24 hours) with adequate hydration 2
• Ear pain without high fever or severe symptoms 6
• Mild respiratory symptoms (runny nose, cough) with fever but no distress 6
• Rash without fever that parent is concerned about 2
• Sore throat in older child without breathing difficulty 6
• Minor injury (fall, bump) with no loss of consciousness or vomiting 6
• Urinary symptoms (pain with urination, frequency) 3
• Mild abdominal pain without severe symptoms 2

ACTION 4: TAKE MESSAGE - PHYSICIAN WILL CALL BACK TO DETERMINE IF VISIT NEEDED

Unclear or borderline situations 4:

• Symptoms don't clearly fit above categories 2
• Parent unsure about severity but child not in distress 7
• Chronic condition with new but mild symptoms 6
• Medication questions or concerns about treatment 4
• Behavioral concerns without acute medical symptoms 1
• Follow-up questions about recent visit or treatment 4
• Request for medical advice (not acute symptoms) 2

HOME CARE ADVICE ONLY (No appointment needed)

Staff should NEVER provide home care advice without physician approval 1. These calls should be categorized as "physician will call back" 4.

Critical Documentation Requirements

For EVERY call, document 1, 4:

• Child's name, age, and date of birth
• Caller's name and relationship to child
• Phone number for callback
• Chief complaint
• All OPQRST information obtained
• Any chronic medical conditions
• Current medications
• Disposition given (911, interrupt physician, appointment, callback)
• Time of call
• Staff member's name

Common Pitfalls to Avoid

• Never minimize parent concern - if parent states "something is very wrong," escalate to physician 1
• Never assume fever alone is benign in infants <3 months - always interrupt physician 6
• Never provide specific medical advice - this is outside staff scope 1
• Never tell parents to wait and see without physician consultation for concerning symptoms 1
• Always ask about chronic conditions - these children have 2-fold increased risk of complications 6
• Don't rely on parent's description of "normal breathing" - ask specific questions about respiratory rate, color, retractions 1
• Document everything - if not documented, it didn't happen from medicolegal perspective 1

Special Populations Requiring Lower Threshold for Physician Consultation

• Infants under 3 months (any fever or concerning symptom) 6
• Children with chronic medical conditions (asthma, diabetes, heart disease, immune compromise, sickle cell disease) 1, 6
• Technology-dependent children 1
• Children with special healthcare needs 1
• Premature infants (especially in first year of life) 5

This tip sheet should be posted at every phone station and reviewed quarterly with all staff 1. Staff should participate in mock scenarios to practice using this framework 1.