Standards › Standard 1 › Forms
Form · REC-FRM-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 1.11
Purpose
The list of entries every patient record must contain, used by the audit.
How to complete
- Complete one form per patient, per area or per period, as the purpose states.
- Tick Yes, No or N/A. Any No is actioned at once and reported to the person named in the procedure.
Checks
| Item to check | Standard reference |
|---|---|
| Patient identity (two identifiers) | Present [E-007] |
| Allergies and alerts | Present [EC] |
| Diagnosis and care plan | Present [EC] |
| Consent (where required) | Present [EC] |
| Medicines given, with time and person | Present [EC] |
| Discharge or transfer summary | Present [EC] |
Evidence
| Reference | Note |
|---|---|
| E-007 | WHO Patient Safety Solutions series (2007). |
| E-009 | ASF Expert Committee consensus. |
Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | — | First approved version | Approved by the ASF Expert Committee |
E-learning for this document
- Incident Reporting, Just Culture and Open Disclosure (T-09)
- Records, Confidentiality and Data Protection (T-11)
- Complaints Handling and Patient Feedback (T-12)
References
- World Health Organization (2007). Nine patient safety solutions, including correct patient identification. Geneva: WHO. Open source (E-007)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)