Improving Documentation of Vital Signs during Triage in Surgical and Orthopedic Patients: A Clinical Audit from a Rural District Hospital

Background: Accurate documentation of vital signs during triage is essential for early recognition of clinical deterioration in surgical and orthopedic patients. In high-volume rural hospitals, incomplete recording of physiological parameters may compromise patient safety. This clinical audit aimed to assess baseline documentation of vital signs during triage and evaluate the impact of a structured, low-cost intervention. Methods: A prospective clinical audit was conducted in a rural district hospital managing surgical, orthopedic, and trauma patients. Adult patients undergoing routine triage in outpatient and emergency departments were included. Five vital signs were audited: pulse, blood pressure, temperature, respiratory rate, and oxygen saturation (SpO 2 ). Baseline data were collected for 250 consecutive patients. A structured intervention consisting of a triage checklist, reminder posters, and brief staff education was introduced. A reaudit was performed for 250 consecutive patients using identical methodology. Documentation rates were compared using Chi-square testing. Results: Baseline documentation rates were highest for pulse (72%) and blood pressure (75.2%), while respiratory rate was least frequently recorded (40%). Following intervention, documentation improved significantly across all parameters, including pulse (96%), blood pressure (97.2%), temperature (92%), respiratory rate (84.8%), and SpO 2 (90%) ( P < 0.001 for all comparisons). Complete documentation of all five vital signs increased from 32% at baseline to 79.2% following intervention. Conclusion: Implementation of a structured triage documentation checklist significantly improved recording of vital signs in a resource-limited rural hospital. Low-cost workflow interventions may enhance patient safety and support standardized triage practices across primary care and district hospital settings.