Emergency triage documentation: An examination of the content and patterns of content

Michelle Jory1, James Hughes2, Rob Eley2, Anthony Tuckett1

1The University Of Queensland, Brisbane , Australia, 2Princess Alexandra Hostpital, Brisbane, Australia

Background: The accurate triaging of patients who present to the Emergency Department is vital for ensuring patients are seen according to a priority attributable to their presenting symptoms. In Australia, nurses assign patients a triage score from 1 to 5 determining time-to-treatment, accompanied by a free-text description of their presenting condition, guided by the ACEM guidelines which are replicated in the Emergency Triage Education Kit. Consistency is required when recording free-text descriptions to ensure safe and quality care.

Methods: A qualitative content analysis of 250 randomised free-text descriptions from a Public Metropolitan Adult Tertiary Referral Hospital, Emergency Department electronic medical record, between November 2015 and November 2016.

Results: Variation in both frequency and order of citation of documented pieces of triage information was evident among the 250 free-text descriptions. The documented information differed among certain presenting problems such as pain presentations and physical injury presentations. Pain presentations were the most commonly documented presenting problem however, documentation of the onset (24.4%), location (65.9%) and description (54.9%) of pain occurred in less than three-quarters of all pain presentations. Documentation of the onset, location and description of pain is essential in providing safe and quality nursing care and in minimising the risk of oligoanalgesia.

Conclusion: Findings indicated different levels of compliance and significant variation in the content and patterns of content of free-text documentation. These findings provide opportunities to create clinical change through recommendations of guideline revisions for both the ACEM and ETEK documents, and renewed triage education and training practices in Australian emergency departments. Further research in triage documentation is necessary in providing a stronger evidence base to support the results from this study.


Michelle Jory is a third year Bachelor of Nursing student from the University of Queensland. Michelle has a particular interest in emergency nursing, emergency care, and emergency triage. Michelle is the first undergraduate nurse to have completed a Summer Research Scholarship Program at the Princess Alexandra Emergency Department and since completion of the eight-week scholarship, has shown an eagerness to complete a research higher degree in the near future.