Standards › Standard S3 › Policies
Policy · PHC-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S3 (Primary care practice), criterion S3.1
At a glance
- Every patient is registered with the practice with their details recorded.
- Every registered patient has a named clinician or team.
- Registration records are reviewed each year and kept current.
- A patient who cannot be registered is told where to go, in writing.
- Stop and get help straight away if: a registered patient has no named clinician or team.
1. Purpose
To make sure every patient is known to the practice and that someone is responsible for their care (S3.1).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
A patient who is not registered, or has no named clinician, falls through the gaps: no one is responsible for their follow-up. A register that is kept current makes every patient someone’s responsibility.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Practice manager | Owns the register and the policy | Management |
| Reception | Registers patients and records the named clinician | Trained in registration |
| Clinical lead | Allocates the named clinician or team | Clinician |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Register.
- Record the patient’s identity, address, contact and carer details.
- Check the identity documents set in the policy.
Key point: No registration without identity.
Step 2. Name a clinician.
- Allocate a named clinician or team and record it on the register.
Key point: Every patient has a name against them.
Step 3. Review.
- Review the register each year for leavers, moves and deaths.
Key point: A register kept current is the basis of all other care.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Registered patients with named clinician | 100% | Quarterly | Practice manager | Escalate to clinical lead |
| Register reviewed in the last 12 months | 100% | Yearly | Practice manager | Escalate to clinical lead |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| PHC-REG-001 | Patient register | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)
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