Standards › Standard S6 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · PTR-SOP-007 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S6 (Patient transfers and referrals), criterion S6.2, S6.32, S6.33, S6.34
At a glance
- Hand over in a structured way at pickup, at each change of segment, and at the destination.
- Use the handover record (HOS-FRM-004) at every handover.
- Written records travel with the patient at every stage.
- Record the name of the person who receives the patient.
- Stop and get help straight away if: a patient changes segment or arrives with no structured handover and no receiver’s name.
1. Purpose
To pass on the patient’s condition and needs clearly at every change, not only at final arrival (S6.2, S6.32, S6.33, S6.34).
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 whose records stay behind cannot be treated safely at the next stop. The paper or electronic record must go with the patient, and the receiving team must be able to find it.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Crew lead | Leads the handover | Trained crew |
| Receiver | Accepts the patient and signs for the record | Receiving team |
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. Prepare.
- Gather the record, the drugs chart and the notes before the handover.
Key point: Records travel with the patient.
Step 2. Hand over.
- Use the structured verbal handover (HOS-SOP-004) and the handover record (HOS-FRM-004).
- Record the handover point and the time.
Key point: Same structure every time.
Step 3. Record the receiver.
- Record the name of the person who receives the patient on the transfer log.
Key point: A name closes the handover.
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 |
|---|---|---|---|---|
| Segments with structured handover recorded | 100% | Monthly | Crew lead | Escalate to clinical lead |
| Handovers with receiver’s name | 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
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| HOS-SOP-004 | Structured verbal handover | Handover |
| HOS-FRM-004 | Handover record | Record |
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 |
E-learning for this document
No e-learning course is linked to this document yet.
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)