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AMT-SOP-001: Transfer logging, handover and record keeping

Standards › Standard S5 › Standard operating procedures (SOPs)

Standard operating procedure (SOP) · AMT-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee

Supports: System S5 (Ambulance and patient transport), criterion S5.3

At a glance

  • Log every transfer from the first call to the outcome.
  • Record each segment, crew, escort and handover point.
  • Record the name of the person who receives the patient.
  • Keep every change and cancellation in the log.
  • Stop and get help straight away if: a patient is moved without a log opened, or a handover is made with no receiver’s name recorded.

1. Purpose

To make every transfer traceable, so that a problem can be found and explained (S5.3).

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

If a transfer is not logged, it cannot be checked when something goes wrong. A log of each transfer, including changes and cancellations, is the record that protects patient and provider.

5. Responsibilities

Role Responsibility Competence
Dispatch lead Opens and closes the log for each transfer Trained dispatcher
Crew lead Records times, segments and the receiver’s name Trained crew

6. Materials and equipment

Item Requirement Condition
Records and forms named in this document Current version Checked before use

7. Safety

8. Before you start

9. Procedure

Step 1. Open the log.

  • Open the transfer log when the request is accepted, with the time and the reason.
  • Record the vehicle, crew and escort.

Key point: No transfer without a log.

Step 2. Record each segment.

  • Record the time of each segment: leaving, arriving, handover, return.
  • Record any change of plan or cancellation with its reason.

Key point: Times make the transfer checkable.

Step 3. Hand over.

  • Record the handover point and the name of the person who receives the patient.
  • Record the outcome given to the receiving team.

Key point: The receiver’s name closes the chain.

Step 4. Close and retain.

  • Close the log before the crew goes off duty.
  • Keep the log under the retention rules in the records policy.

Key point: A log closed late is still a log.

10. Decision points

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

13. Monitoring

Measure Target Frequency Owner If not met
Transfers with a complete log 100% Monthly Dispatch lead Escalate to clinical lead
Handovers with receiver’s name recorded 100% Monthly Crew lead 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

16. Related documents

ID Title Use
AMT-FRM-001 Transfer log Log
AMT-REG-002 Receiving service agreements register Register

17. Evidence

Reference Note
E-009 ASF Expert Committee consensus. Based on the WHO Patient Safety Curriculum Guide (2011) on handover.
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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