Standards › Standard S3 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · PHC-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S3 (Primary care practice), criterion S3.3
At a glance
- Book patients with their usual clinician or team where it is clinically appropriate.
- Keep the record in one place that the whole team can read.
- Any team member who sees the patient writes the key points.
- Review the access list each year.
- Stop and get help straight away if: a team member cannot find the history needed for a patient they are seeing.
1. Purpose
To keep one story for each patient, so that any team member can continue their care (S3.3).
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
Patients who see a different clinician each visit repeat their history, and important details are lost. Continuity means one clinician or team holds the story, and records move with the patient.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Practice manager | Owns booking rules and the access list | Management |
| Clinicians | Write key points; use the usual clinician rule | 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. Book.
- Offer the usual clinician or team first, where it is appropriate.
Key point: Continuity starts at booking.
Step 2. Record.
- Write the key points of each visit in the shared record.
Key point: Write for the next clinician.
Step 3. Check access.
- Check the access list each year against the team list.
Key point: Only current staff have access.
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 |
|---|---|---|---|---|
| Patients seen by usual clinician where appropriate | At least 70% | Quarterly | Practice manager | Escalate to clinical lead |
| Access list reviewed in the last 12 months | 100% | Yearly | Practice manager | Escalate to chief executive |
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-FRM-001 | Shared record access check | Check record |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| 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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