Standards › Standard 18 › Standard operating procedures (SOPs)
Procedure · PHY-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 18.4
At a glance
- Measure progress at set intervals against the goals agreed at assessment.
- Use a measure that suits the condition, recorded on PHY-FRM-003.
- When progress stops, change the plan and record why.
- Review progress at least once a month for each patient in an ongoing course.
- Stop and get help straight away if: a patient is treated for months with no measurement.
1. Purpose
To make sure treatment progress is measured, and the plan changed when progress stops (18.4).
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 treatment without measured progress cannot be shown to work, and it is easy to continue for months with no benefit. Measuring progress at set intervals tells the team when to change the plan.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Treating physiotherapist | Measures progress and changes the plan | 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. Measure.
- Measure progress at the set interval, against the agreed goals.
Key point: Measured.
Step 2. Record.
- Record the measure on PHY-FRM-003.
Key point: Recorded.
Step 3. Change the plan.
- When progress stops, change the plan and record the change.
Key point: Plan changed.
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 with progress measured at the set interval | 95% | Monthly | Lead physiotherapist | Escalate to medical director |
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 |
|---|---|---|
| PHY-FRM-003 | Progress record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WCPT Descriptor of physical therapy (2019) and the WHO Rehabilitation in health systems guide (2019). |
| 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
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)