Standards › Standard 24 › Policies
Policy · MTR-POL-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 24.6
At a glance
- Keep a list of the travel documents needed for each destination, and check it each year.
- Issue the documents the patient needs, correctly and promptly (MTR-FRM-004).
- Give a fitness letter where the patient needs one to fly, before travel.
- Do not leave the patient to find out what is required.
- Stop and get help straight away if: a patient is unable to fly because the fitness letter was missing.
1. Purpose
To make sure each patient gets the right documents for travel, in time (24.6).
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
An international patient often needs letters and forms to travel, such as a fitness-to-fly letter. Wrong or missing documents can stop them from flying home.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| International patient coordinator | Keeps the list and issues the documents | Manager |
| Treating clinician | Signs the fitness letter | 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 list.
- Check the document list for the patient’s destination.
Key point: Checked.
Step 2. Issue.
- Issue each document needed, in time for travel, and record it on MTR-FRM-004.
Key point: Issued.
Step 3. Fitness letter.
- Where needed, issue a fitness letter before travel.
Key point: Issued.
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 documents issued in time for travel | 100% | Monthly | International patient coordinator | 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 |
|---|---|---|
| MTR-FRM-004 | Travel document issued record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Patient Safety Curriculum Guide (2011) and the NICE guidance on venous thromboembolic diseases (NG158, 2020). |
| 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)