Triage Documentation Audit

• Site conducted

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• Conducted on

  Date

• Prepared by

• Location
  Address

• MRN

• Nurse in visual

• Nurse in triage

TRIAGE DOCUMENTATION

• Visual triage documented accuratelly

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FALL RISK SCREENING

• Use of appropriate and complete assessment tool.

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• Ensure correct total score and in plan of care including fall prevention and precautions is to be implemented. Ensure preventive actions and interventions are ticked

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• General consent completed

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• Main complaints documented

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• PAIN ASSESSMENT, REASSESSMENT documented accurately

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• Sepsis Screening accurately done according to the Sepsis pathway and activated accordingly

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• Triage Acuity and triage completed

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• Height and weight documented accurately

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• Patient allergy reviewed

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• Home Medication reviewed

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• Patient history reviewed and documented

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• Re-triage or reassessment of vital sign completed if indicated

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