ED Triage Acuity Reassessment Audit

Audit of emergency department waiting room patient reassessment intervals based on assigned ESI level and time since initial triage, with focus on timely follow-up, documentation, and escalation of changes in condition.

Audit Identification

• Patient encounter and audit record identified
  Record the encounter identifier, audit date, and auditor name or role.
• Initial triage time documented
  Capture the date and time of the initial triage assessment.
• Assigned ESI level documented
  Select the Emergency Severity Index level assigned at triage.
• Waiting room status at time of review confirmed
  Confirm whether the patient remained in the waiting room, was roomed, discharged, transferred, or left before reassessment review.

Reassessment Interval Compliance

• Time from triage to first reassessment recorded
  Enter the number of minutes from initial triage to the first documented reassessment while the patient was waiting.
• Reassessment interval appropriate for assigned ESI level
  Verify whether the reassessment occurred within the facility's expected interval for the assigned ESI level and elapsed waiting time.
• Subsequent reassessments completed at required interval
  If the patient remained in the waiting room after the first reassessment, verify that additional reassessments were completed at the required interval.
• Delay beyond expected reassessment interval documented with reason
  If reassessment was late, verify that the delay reason was documented and clinically justified.

Clinical Status Change and Escalation

• Change in condition assessed during waiting period
  Verify whether the reassessment documented any change in pain, vital signs, appearance, mental status, respiratory effort, bleeding, or other deterioration.
• Escalation initiated for worsening condition
  If the patient worsened, verify that the patient was escalated to a higher-acuity provider review, moved to treatment area, or otherwise prioritized appropriately.
• Vital signs or focused reassessment findings documented when indicated
  Verify that vital signs or focused reassessment findings were recorded when required by the patient's presentation or reassessment protocol.
• Patient left without being seen or left before reassessment addressed
  Record whether the patient left before reassessment, and whether follow-up or notification steps were completed per policy.

Documentation Quality

• Reassessment note includes time, findings, and disposition impact
  Verify that the reassessment note includes the time of reassessment, key findings, and any impact on triage priority or disposition.
• Documentation is legible, complete, and attributable
  Verify that the reassessment documentation is complete, clearly attributable to a clinician, and free of conflicting entries.
• Triage reassessment protocol or SOP referenced in chart or audit record
  Verify whether the applicable triage reassessment protocol, SOP, or local policy is identified in the audit record when needed for review.
• Documentation gaps identified
  Select all documentation deficiencies observed during the audit.

Corrective Actions and Closeout

• Deficiency or non-conformance identified
  Indicate whether any deficiency, non-conformance, or critical item failure was identified during the audit.
• Corrective action assigned
  Describe the corrective action, owner, and due date for any identified gap.
• Audit outcome summarized
  Rate the overall quality of reassessment compliance for this encounter.
• Auditor attestation complete
  Auditor confirms the review is complete and accurate.