Standards › Standard 9 › Plans and templates
Plan · FLD-PLN-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 9.11
At a glance
- The plan names the permanent service that receives each patient and record.
- Each patient is transferred with a written handover (HOS-FRM-004).
- Records are transferred or stored under REC-POL-001.
- Closure is recorded with the count of patients and records transferred.
- Stop and get help straight away if: the unit closes with a patient or record unaccounted for.
1. Purpose
To move each patient and record to a permanent service when the unit closes or hands over (9.11).
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
A field unit is temporary, but its patients are not. When it closes, the patients and their records must go to a permanent service, or care stops.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Field unit lead | Owns the closure and names the receiving services | Clinician |
| Records lead | Checks every record moves | Records |
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. Name the receiving service.
- Name the permanent service for each open patient before closure.
Key point: A service for each patient.
Step 2. Hand over.
- Hand over each patient with HOS-FRM-004, and move each record.
Key point: A written handover each.
Step 3. Close and count.
- Count patients and records transferred, and record the closure.
Key point: Nothing unaccounted for.
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 and records accounted for at closure | 100% | Each closure | Field unit lead | Escalate to the coordinating authority |
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-FRM-004 | Handover record (existing, reused) | Record |
| REC-POL-001 | Records management and retention (existing, reused) | Policy |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on WHO classification and minimum standards for emergency medical teams (2013). |
| 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)