Standards › Standard 30 › Standard operating procedures (SOPs)
Procedure · FW-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 30.2
At a glance
- A member returning after injury, surgery or a medical event has documented medical clearance first (FW-FRM-002).
- The programme is built from a functional assessment (FW-FRM-003) and progresses at the pace of readiness.
- Staff are qualified for post-injury programming (FW-REG-001), and oversee or deliver it.
- The programme stops and the member is referred back when warning signs appear (FW-SOP-002).
- Stop and get help straight away if: a member who had knee surgery starts heavy lifting the next week.
1. Purpose
To make sure post-injury return to activity is safe, cleared, assessed, qualified and monitored (30.2 to 30.4).
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 member who has had surgery or a serious injury must not start hard exercise without their doctor’s clearance. Without it, the exercise can undo the recovery or cause a new injury.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Fitness service lead | Owns the return-to-activity rule | Clinician or manager |
| Qualified rehabilitation instructor | Builds and delivers the programme | 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. Clear.
- Obtain and record the medical clearance and its restrictions on FW-FRM-002.
Key point: Cleared.
Step 2. Assess and plan.
- Carry out the functional assessment and set the progression on FW-FRM-003.
Key point: Planned.
Step 3. Deliver under qualification.
- Deliver or oversee the programme with a qualified instructor.
Key point: Delivered.
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 |
|---|---|---|---|---|
| Post-injury members with clearance, assessment and qualified oversee | 100% | Monthly | Fitness service lead | 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 |
|---|---|---|
| FW-FRM-002 | Medical clearance record | Record |
| FW-FRM-003 | Functional assessment and programme record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO guidance on digital health and data protection, the American College of Sports Medicine Guidelines for Exercise Testing and Prescription (11th ed., 2021), and the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care (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)