Standards › Standard S1 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · HOS-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S1 (Hospital), criterion S1.1
At a glance
- Triage every arrival with the named triage tool, within the set time.
- Write the category and the time on the record.
- Keep triage staffed whenever the emergency area is open, including nights.
- The most urgent patient is seen first, whatever the arrival order.
- Stop and get help straight away if: a patient is waiting with no triage category or no triage nurse is on duty.
1. Purpose
To sort every patient who arrives for emergency or urgent care by clinical urgency, so that the most urgent are seen first (S1.1).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Triage tool | The named, recognised tool used to assign a category at arrival |
| Category | The urgency level given by the tool |
4. Background
Triage decides who is seen first. Without a recognised tool, the sickest patient can wait behind the least sick, and nobody can show why.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Triage nurse | Triages every arrival; records category and time | Trained in the named tool |
| Duty clinical lead | Reviews any patient waiting beyond the set time | Senior clinician |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Greet and start the record.
- Record the arrival time and name.
- Check the immediate danger signs at the door.
Key point: Danger signs are acted on before the full triage.
Step 2. Apply the tool.
- Score the patient with the named tool.
- Assign the category.
Key point: The tool decides, not the first available nurse.
Step 3. Record and place.
- Write the category and the time on the record.
- Place the patient in the waiting order for that category.
Key point: The record is the proof.
Step 4. Re-triage while waiting.
- Re-check each waiting patient at the interval set for the category.
- Upgrade if the condition changes.
Key point: A waiting patient can get worse.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Arrivals with a category and time recorded | 100% | Monthly | Triage lead | Escalate to clinical director |
| Patients seen within the time for their category | At least 70% | Monthly | Triage lead | Review triage staffing |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| HOS-FRM-001 | Triage record and log | Record used in step 3 |
| HOS-SOP-002 | Vital signs and deterioration response | Re-triage and observations |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Set time limits set by the ASF Expert Committee by the Committee and the national triage tool. |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)