Screening Questions at Triage

Originally approved October 2016

Approved by the Emergency Nurses Association Board of Directors, September 2016 


Triage is a rapid evaluation of patient acuity for the purpose of establishing the order and/or the location in which the patient should be seen by an emergency care provider and may be bypassed when patient care space and staff are immediately available. Optimal patient care occurs when the length of time between the patient’s presentation and the time that the patient is seen by an emergency care provider is as short as possible.

Delays can occur when regulatory questions are routinely asked of patients during initial triage. Although screening for depression, substance abuse and domestic violence can provide important information about the care some patients may require, the routine inclusion of general screening questions in the initial triage process creates a preventable delay in caring for patients. Screening information should be obtained after the initial prioritization process is complete and should not interfere with timely access to needed care. 

The American College of Emergency Physicians and the Emergency Nurses Association support initial triage processes that limit the focus and content of questions to information pertinent to the patient’s condition to determine the priority in which patients should be seen by an emergency care provider.

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