Standards › Standard 34 › Policies
Policy · REH-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 34.1
At a glance
- Each rehabilitation patient has a functional assessment before the plan is written (REH-FRM-001).
- Interventions link to the impairment found in the assessment.
- Generic protocols are not applied without an assessment.
- The plan is reviewed when the patient’s function changes.
- Stop and get help straight away if: a rehabilitation plan is started with no functional assessment on file.
1. Purpose
To make sure every rehabilitation plan is built on what the patient can and cannot do, not on a standard protocol (34.1).
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 rehabilitation plan copied from another patient does not fit the person in front of you. A plan built from a functional assessment, specific to this patient’s goals and abilities, is what makes rehabilitation work.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Rehabilitation lead clinician | Owns the plan and its review | Clinical director |
| Treating therapist | Carries out the functional assessment and writes the plan | Rehabilitation lead 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. Assess.
- Carry out a functional assessment of the patient’s mobility, self-care, communication and participation.
Key point: Assessed.
Step 2. Plan.
- Write the plan from the assessment, with goals and interventions linked to each impairment (REH-FRM-001).
Key point: Planned.
Step 3. Review.
- Review the plan when function changes, and record the change.
Key point: Reviewed.
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 |
|---|---|---|---|---|
| Plans preceded by a functional assessment | 100% | Monthly | Rehabilitation lead clinician | Escalate to the clinical 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 |
|---|---|---|
| REH-FRM-001 | Rehabilitation plan record | Record |
| PHY-FRM-001 | Physiotherapy assessment record (existing) | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on WHO Rehabilitation in Health Systems (2019), the Global Patient Safety Action Plan 2021–2030, and the ASF Fitness and Wellness and Aftercare standards. |
| 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)