Standards › Standard 21 › Policies
Policy · URG-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 21.1
At a glance
- Each patient is sorted by clinical urgency on arrival, using a recognised triage tool (URG-FRM-001).
- A patient with a potential emergency is seen at once, not left in the waiting room.
- Patients who need emergency care are sent to a hospital without delay.
- The triage decision and the time are recorded for every patient.
- Stop and get help straight away if: a patient with a potential emergency is left in the waiting room unseen.
1. Purpose
To make sure every patient is sorted by urgency on arrival, and emergencies are seen and sent on at once (21.1).
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 |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
In an urgent care service, the patient who is having a heart attack may arrive behind a patient with a sprain. Sorting patients by clinical urgency on arrival is what makes sure the sickest are seen first.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead | Owns the triage tool and the rule | Clinician |
| Triage nurse or doctor | Triages each patient on arrival | 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. Triage on arrival.
- Triage each patient with the recognised tool, and record the category and time (URG-FRM-001).
Key point: Triaged.
Step 2. Act on emergencies.
- See a potential emergency at once. Send an emergency to hospital without delay.
Key point: Acted on.
Step 3. Review the rule.
- Review triage records each month against the rule.
Key point: Reviewed.
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 |
|---|---|---|---|---|
| Patients triaged on arrival with time recorded | 100% | Monthly | Clinical lead | Escalate to medical director |
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 |
|---|---|---|
| URG-FRM-001 | Triage record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Emergency triage, assessment and treatment (ETAT) manual (2005) and the WHO Emergency care systems for universal health coverage (2016). |
| 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 |
E-learning for this document
- Acute & Same-Day Care (PHC-04)
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)