Professional considerations
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When I record my triage encounter face-to-face, I write everything down and that is my record of what has happened. But I am aware that if I am talking to somebody on the telephone, they may be recording what I say and that will be the record as well as the records that I write on the computer.
Firstly, the fact that your conversation has been recorded is actually really good and it is beneficial to you and that will act as support for you if your notes are questioned or your decision-making is questioned and the service will actually record all telephone conversations. Your notes, you are absolutely correct. Exactly the same as doing a face-to-face, you need to document as much relevant information, so the history-taking, anything that has been disclosed to you. Say, for example, somebody suggested there may be a child at risk. Obviously, that is a massive concern and that needs to be documented within your documentation, but also this would need to be flagged up as a safeguarding concern. You would also report it via your organisation's incident reporting system and it may be that, in the out of hours period, the police need to become involved in this as well.
If we are talking about adults who may be vulnerable, if we have had anything flagged to us, this needs to be reported to the local safeguarding boards. It is absolutely crucial, Mark, that you are documenting as much information in these incidents as possible. And the other thing I would say to you about is you need to think about acting ethically, especially when we are talking about palliative patients. And you need to get as much information about these patients, the do-not-attempt-CPR plans, any ReSPECT paperwork that may be in place or advanced care plans. You need to have this information discussed with you, between you and the family, so that you have got as much information to help you to come to your decision-making at the end of the process.