Documentation of the triage assessment and severity rating needs to be clear, concise, and complete. Most hospitals have developed documentation forms or utilize a computerized system. Important documentation elements to include are:

• patient name
• date and time of arrival
• mode of arrival
• triage interview time
• patient age
• prehospital interventions
• first-aid measures
• allergies
• immunization status (pediatric patients)
• cultural assessment, including language spoken
• current medications
• vital signs
• level of pain
• chief complaint
• assessment findings
• medical history
• domestic violence
• last menstrual period (for females of childbearing age)
• last tetanus immunization
• fall risk
• triage severity rating
• diagnostic tests initiated
• medications administered
• nursing interventions
• triage reassessment.