Standards › Standard 34 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · REH-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 34.2
At a glance
- The disciplines involved in each patient’s care are named in the plan.
- The team reviews each patient at the set interval (REH-REG-001).
- Conflicting instructions are resolved by a named lead clinician.
- Each review is recorded.
- Stop and get help straight away if: two disciplines give conflicting instructions with no lead clinician named.
1. Purpose
To make sure physiotherapy, occupational therapy, speech-language therapy, rehabilitation medicine and nursing work from one plan (34.2).
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 patient often sees a physiotherapist, an occupational therapist, a doctor and a nurse. If they give conflicting advice, the patient is confused and recovery slows.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Rehabilitation lead clinician | Leads the team and resolves conflicts | Clinical director |
| Each discipline | Attends reviews and follows the agreed 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. Name the team.
- Name the disciplines involved for each patient in the plan.
Key point: Team named.
Step 2. Review.
- Hold the team review at the set interval and record it (REH-REG-001).
Key point: Reviewed.
Step 3. Resolve.
- Resolve any conflict in instructions with the lead clinician and record the decision.
Key point: Resolved.
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 team reviews at the set interval | 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-REG-001 | Team review register | Register |
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)