Standards › Standard S6 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · PTR-SOP-013 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S6 (Patient transfers and referrals), criterion S6.10
At a glance
- The patient is told about the transfer and can decline it.
- The reason for the transfer and the risks of declining are explained.
- For a patient who cannot consent, the route in the consent policy applies.
- The decision is recorded.
- Stop and get help straight away if: a competent patient is transferred against their decision without the route in the consent policy being followed.
1. Purpose
To respect the patient’s right to decline transport and to set the route when the patient cannot consent (S6.10).
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 have the right to refuse transport. The transfer detail adds the right to decline and the route to a decision for a patient who cannot give consent themselves.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinician | Explains the transfer and the risks of declining | Doctor or nurse |
| Crew lead | Records the decision | Trained crew |
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. Explain.
- Explain the transfer, why it is needed, the risks and the alternatives, in a language the patient understands.
Key point: Informed before agreed.
Step 2. Decide.
- The patient agrees or declines.
- If declined, record it and inform the referring clinician.
Key point: The patient decides.
Step 3. Cannot consent.
- Follow the consent policy for a patient who cannot consent (T-07 applies).
Key point: A legal route exists.
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 |
|---|---|---|---|---|
| Transfers with consent or decline recorded | 100% | 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 |
|---|---|---|
| T-07 | Patient identification, informed consent and patient rights | Course |
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
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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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