Standards › Standard S6 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · PTR-SOP-005 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S6 (Patient transfers and referrals), criterion S6.13, S6.14, S6.11
At a glance
- The escort doctor holds the qualification and recent experience for the patient’s condition and the mode.
- The escort stays with the patient until the agreed handover point.
- If the escort cannot continue, a named alternative takes over before the patient is left unescorted.
- Credentials are checked before each transfer.
- Stop and get help straight away if: a patient is left unescorted, or an escort without the required qualification travels.
1. Purpose
To make sure every escort is qualified for the patient and stays with them until handover (S6.13, S6.14, S6.11).
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
The crew’s skills must match the acuity of the patient. A crew trained only for basic care cannot safely manage a patient who needs advanced interventions.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead | Confirms the escort’s qualification and experience | Clinician |
| Escort | Stays with the patient to the handover point | 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. Check the escort.
- Check the escort’s qualification and recent experience against the patient’s condition (PTR-REG-001).
- Record the check on the plan.
Key point: Right escort for this patient.
Step 2. Stay with the patient.
- The escort does not leave the patient until the agreed handover point.
- If the escort cannot continue, name the alternative and hand over before leaving the patient.
Key point: Never unescorted.
Step 3. Hand over the escort.
- Record the alternative escort’s name and the time they took over.
Key point: A named person takes over.
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 |
|---|---|---|---|---|
| Escorts with qualification checked before transfer | 100% | Monthly | Clinical lead | Escalate to chief executive |
| Patients left unescorted | 0 | Monthly | Clinical lead | 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 |
|---|---|---|
| PTR-REG-001 | Escort and crew credential and pre-shift register | Register |
| PTR-SOP-006 | In-transit monitoring and deterioration | Monitoring |
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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