PHC-POL-002: Managed conditions and first-contact care list

Policy · PHC-POL-002 · Version 1.0 · Approved by the ASF Expert Committee

Supports: System S3 (Primary care practice), criterion S3.2

At a glance

The practice keeps a written list of the conditions it manages.
Staff know the route for every condition not on the list.
The list is reviewed every year.
Changes to the list are agreed by the clinical lead.
Stop and get help straight away if: a patient is managed for a condition not on the list, with no decision recorded.

1. Purpose

To make clear what the practice can and cannot manage, so that patients get the right care in the right place (S3.2).

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 practice that does not know which conditions it manages will send everything elsewhere, or manage things it cannot. A written list of managed conditions and a clear referral route keep first-contact care safe.

5. Responsibilities

Role	Responsibility	Competence
Clinical lead	Owns the list and the routes	Clinician
Clinicians	Manage listed conditions; refer others by the route	Trained

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. Write the list.

List the conditions the practice manages, with the standard of care for each.

Key point: The list is the agreement.

Step 2. Set the route.

For each condition not on the list, write the referral route.

Key point: Staff should not have to guess.

Step 3. Review.

Review the list each year and when guidance changes.

Key point: Guidance changes; the list must follow.

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
List reviewed in the last 12 months	100%	Yearly	Clinical lead	Escalate to chief executive
Staff who know the route	At least 70%	Yearly	Clinical lead	Retrain

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-SOP-001	Routing conditions not managed	Route used in step 2
PHC-SOP-003	Referral criteria and tracking	Referral

17. Evidence

Reference	Note
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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