2.  The purpose of the triage interview is to gather
enough information to make a clinical judgment
for priority of care.
 Triage is not a final medical diagnosis

3.  To rapidly identify patients with urgent, life
threatening conditions.
 To determine the most appropriate treatment area
for patients presenting to the ED.
 To decrease congestion in emergency treatment
areas.
 To provide ongoing assessment of patients.
 To provide information to patients and families
regarding services expected care and waiting
times.

4.  Greets client and family in a warm empathetic
manner.
 Performs brief visual assessments.
 Documents the assessment.
 Triages clients into priority groups using
appropriate guidelines.
 Transports client to treatment area when
necessary.

5.  Gives report to the treatment nurse or emergency
physician
 Keeps patients/families aware of delays.
 Reassesses waiting clients every 30 min and re-
triages to upgrade if necessary, then informs
charge nurse.
 Instructs clients to notify triage nurse of any
change in condition.
 Checks waiting room every 30 min or when
available.

6.  Use open-ended questions to help elicit feelings
and perceptions along with information
 Use close-ended questions to get facts ( yes or
no answer)
 Effective triaging requires nurses to use all their
senses: smell, touch, sight, hearing-please don’t
taste anything….
 Look for non verbal clues: facial grimaces,
cyanosis, fear, euphoria
 Listen for cough, hoarseness, labored
respirations

7.  Smell for ketones, alcohol, infection,
gangrene
 Touch skin to feel for coolness or warmth or
clamminess.
 Physical Assessment should be rapid, concise,
and focused
 In some patients vital signs may be
reasonable, while in others it is a description
of physical signs

8.  Interview should not be longer than 2-5 minutes
 Triage interview is not a full head to toe
assessment. Head to toe assessment is the
responsibility of the assigned/treatment nurse.
 Surgical history will tell you a lot if you ask..

9.  If you are not sure what to categorize
patient as, you can ask for help from
physician or charge.
 Over triage rather than under triage if not
very certain.

10. When describing location of abdominal pain do
not just write abdominal pain but instead use:
 Right upper/lower quadrant
 Left upper/lower quadrant
 Epigastric
 Umbilical area (center)
 By pinpointing the location of pain, physician
and nurse will have a better idea of what to
expect rather than saying abdominal pain
which is vague (remember to describe this
pain

11.  Attitude, empathy, compassion are important aspects
of the triage nurse’s demeanor.
 Try to calm patient and family anxiety if able to
explain, or bring someone to translate. Remember
some are afraid when they come not knowing what to
expect.
 Remain consistent and non-judgmental towards all
patients.
 Any element of prejudice, can increase patient risk
due to incorrect assignment of triage level/category

12. Do not prejudge patients based
on their appearance or attitude
as this may lead to under
categorizing

13. A triage level must be recorded
on all patients, during all shifts.
This includes all ambulance
patients, code patients, RRT.

14. What brought the patient to ER today? This is the
patient’s statement.

15.  The triage nurse must check the site in order to
make assessment and to categorize (eg. All
wounds, in situ catheters, tubes)
 If site is dressed/covered, remove dressing and
take a look. Then put a temporary dressing until
patient is seen by physician.

16.  This is the information provided by the patient.
 When did pain/discomfort start (be exact with
time)? Describe character of pain and severity.
Use pain scale 1-10.
 Is pain dull or sharp, pressure like, crushing,
stabbing?

17.  What were you doing when it started?
 How long did it last?
 Does it radiate (from where to where)
 Is pain intermittent
 Does anything make it better or worse?
 Any history of the same pain? Were you
diagnosed previously?

18. This is the nurses assessment, what do you see?
 Does patient “look sick” or look well
 Look at skin color (paleness, jaundice,
diaphoretic, discoloration, flushing of skin etc..)
 Is skin cool and clammy, warm
 Difficulty speaking due to hx of stroke or SOB?
 Can you smell anything? Ketones, alcohol etc

19.  Language barrier
 Hearing disability
 Difficulty speaking or slurred speech
 Mental competency
 Age
 Pain level
 Anger