Standards › Standard 29 › Policies
Policy · HC-POL-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 29.16
At a glance
- A non-clinical caregiver may remind a client to take a medicine, but does not give an injection or other clinical administration.
- Administration is done only by staff with clinical training, under supervision.
- The task each caregiver may perform is written on the care plan.
- A caregiver who is asked to do a task beyond their scope refuses and reports it.
- Stop and get help straight away if: an untrained caregiver gives an injection.
1. Purpose
To keep reminders and clinical administration apart, and within each person’s scope (29.16).
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
Reminding a client to take a medicine is different from giving it. A non-clinical caregiver may remind, but only a trained person may give or manage a medicine. Confusing the two causes harm.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead for home care | Owns the scope of tasks | Clinician |
| Caregiver | Performs only the tasks in scope | Staff |
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. Set the scope.
- Write which tasks each role may perform on the care plan.
Key point: Set.
Step 2. Check the task.
- Before each medicine task, check it is within the caregiver’s scope.
Key point: Checked.
Step 3. Report.
- Report any task beyond scope and refuse it.
Key point: Reported.
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 |
|---|---|---|---|---|
| Medicine tasks within the caregiver’s scope | 100% | Monthly | Clinical lead for home care | 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 |
|---|---|---|
| LTC-SOP-002 | Medicine reconciliation (existing, reused) | Procedure |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Global strategy and action plan on ageing and health 2016-2030, WHO Integrated care for older people (ICOPE) guidelines (2017), and WHO guidance on migrant health. |
| 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)