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Run: ED Triage Acuity Reassessment Audit

Audit ED waiting room reassessments against ESI-based intervals, escalation triggers, and documentation quality. Use it to catch delayed follow-up, missed de...

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Audit Identification

Patient encounter and audit record identified

Record the encounter identifier, audit date, and auditor name or role.

Initial triage time documented critical (required)

Capture the date and time of the initial triage assessment.

Assigned ESI level documented critical (required)

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 critical (required)

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 critical (required)

Verify whether the reassessment occurred within the facility's expected interval for the assigned ESI level and elapsed waiting time.

Yes No N/A

Subsequent reassessments completed at required interval critical (required)

If the patient remained in the waiting room after the first reassessment, verify that additional reassessments were completed at the required interval.

Yes No N/A

Delay beyond expected reassessment interval documented with reason

If reassessment was late, verify that the delay reason was documented and clinically justified.

Yes No N/A

Clinical Status Change and Escalation

Change in condition assessed during waiting period critical (required)

Verify whether the reassessment documented any change in pain, vital signs, appearance, mental status, respiratory effort, bleeding, or other deterioration.

Yes No N/A

Escalation initiated for worsening condition critical (required)

If the patient worsened, verify that the patient was escalated to a higher-acuity provider review, moved to treatment area, or otherwise prioritized appropriately.

Yes No N/A

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.

Yes No N/A

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 critical (required)

Verify that the reassessment note includes the time of reassessment, key findings, and any impact on triage priority or disposition.

Yes No N/A

Documentation is legible, complete, and attributable

Verify that the reassessment documentation is complete, clearly attributable to a clinician, and free of conflicting entries.

Yes No N/A

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.

Yes No N/A

Documentation gaps identified

Select all documentation deficiencies observed during the audit.

Corrective Actions and Closeout

Deficiency or non-conformance identified critical (required)

Indicate whether any deficiency, non-conformance, or critical item failure was identified during the audit.

Yes No N/A

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.

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