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Back to Standards/Criterion 14.2.2.16
14.2.2.16New in the 7th Edition
Facilities and equipment

Emergency Triage System Protocol 2.2

The Emergency Medical and Trauma Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for emergency triage system.

Compliance Criteria

  • 1Approved standard operating procedure for emergency triage system reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day emergency triage system compliance
  • 3Regular documentation audits and evidence of corrective action implementation
  • 4Staff training records and competency assessments maintained in the department

Hospital Self-Rating

Rated by Dr. Nurul Huda on 16 Jan 2026

Evidence frozen on 30 March 2026 (14 days before survey)

"The department has established comprehensive operational policies for emergency triage system. Regular self-assessments and internal quality checks demonstrate consistent compliance across all operational shifts."

Evidence Documents (0)

A criterion with no document reads as unevidenced to the survey team.

Attach relevant hospital policies, registers, audit reports, or training records.

NH
Person-in-ChargeEmergency Medicine Specialist
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Dr. Mohd Anis Haron (Lead Surveyor)

Surveyor Rating

Committed 14 Apr 2026

Review of emergency triage system monitoring files in Emergency Medical and Trauma Services identified overdue quarterly audits and incomplete corrective action verification.

Establish continuous supervisory sign-off audits and enforce documented shift compliance for emergency triage system.

Implement monthly documentation audits and review adherence rates during departmental quality meetings.