Emergency Room Triage Assessment
Patient Information
Patient Name
Date of Birth
Age
Gender
Female
Male
Other
Medical Record Number
Arrival Time
Chief Complaint
Chief Complaint
Vital Signs
Temperature (°C)
Pulse (bpm)
Respiratory Rate
Blood Pressure (mmHg)
SpO
2
(%)
Pain Score
Assessment
Brief History / Presentation
Physical Exam Findings
Interventions/Actions Taken
Triage Level
Triage Category
1 - Resuscitation (Immediate)
2 - Emergent (Within 15 min)
3 - Urgent (Within 30 min)
4 - Semi-Urgent (Within 60 min)
5 - Non-Urgent (Within 120 min)
Notes
Additional Notes
Triage Nurse
Date