Standards › Standard 29 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · ED-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 29.1
At a glance
- Every patient who arrives at the emergency department is triaged on arrival, before waiting.
- Triage is done by a trained clinician on the recognised triage scale named in this procedure.
- The category and the time of triage are recorded on the triage record (ED-FRM-003).
- The maximum time to clinical assessment is set for each category and is checked.
- Stop and escalate straight away if a patient waits without triage.
1. Purpose
To make sure every person who arrives at the emergency department is triaged on arrival, so that the most urgent patients are seen first (29.1).
2. Scope
| Applies to | Triage nurses, emergency physicians and emergency nurses, and the head of the emergency department |
| Locations | The emergency department reception and triage area, and any place where patients wait |
| When | At every arrival, at any time of day or night, including without an appointment |
3. Definitions
| Triage | Sorting of patients on arrival by urgency, so that the most urgent are seen first. |
| Recognised triage scale | The triage tool named in section 5 of this procedure, used the same way by every trained clinician. |
| Triage category | The urgency category given to a patient by the triage scale. |
| Time to assessment | The time from arrival to the start of clinical assessment, set for each triage category. |
4. Responsibilities
| Role | Responsibility |
| Head of emergency department | Names the triage scale, sets the maximum time to assessment for each category, and reviews the procedure. |
| Triage nurse | Triages every arrival on the named scale and records the category and time on ED-FRM-003. |
| Emergency physician | Assesses patients in category order and confirms the category when it changes. |
5. Procedure
- Register the arrival and start triage at once. Do not hold a patient in the waiting room before triage.
- Triage by a trained clinician on the recognised triage scale named by the head of emergency department.
- Record the triage category and the time of triage on the triage record (ED-FRM-003).
- Assess the patient within the maximum time for the category. If that time is at risk, tell the senior clinician.
- Keep the record with the attendance so that the time to triage can be checked.
6. Escalation
If a patient is found waiting without triage, triage the patient immediately, record the delay, and inform the senior clinician on duty (ED-FRM-001).
7. Monitoring
The head of emergency department reviews a sample of attendances across shifts, including nights and weekends, to check that every arrival was triaged before waiting and that the maximum time to assessment was met.
8. Related documents
- ED-FRM-003 Triage record and log
- ED-FRM-001 Senior clinician on duty record
- ED-POL-001 Senior clinician responsibility and specialist escalation
9. Evidence
Triage records (ED-FRM-003) for the sample period, and the named triage scale in this procedure.
10. Change history
| Version | Date | Change |
| 1.0 | 1 November 2026 | First version. Approved. |
E-learning for this document
References
- WHO (2021). Emergency Triage Assessment and Treatment (ETAT): Manual for Participants. Child-specific. Child-specific; the triage scale is named by the facility.