Standards › Standard 34 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · REH-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 34.3
At a glance
- Goals are set with the patient and, where the patient agrees, with family (REH-FRM-002).
- Goals are written in plain language.
- Realistic expectations are explained and the understanding is checked.
- The patient’s agreement is recorded.
- Stop and get help straight away if: goals are set without the patient’s involvement or agreement.
1. Purpose
To make sure rehabilitation goals belong to the patient and that expected recovery is understood (34.3).
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 patient who helps set their own rehabilitation goals is more likely to work towards them. Their family, where appropriate, can help them reach those goals at home.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Treating therapist | Sets goals with the patient and explains expectations | Rehabilitation lead clinician |
| Rehabilitation lead clinician | Checks goal records at each review | Clinical director |
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. Ask.
- Ask the patient what they want to achieve, and agree the goals with them and, where they agree, their family.
Key point: Asked.
Step 2. Explain.
- Explain realistic expectations in plain language and check understanding.
Key point: Explained.
Step 3. Record.
- Record the goals, the expectations and the patient’s agreement (REH-FRM-002).
Key point: Recorded.
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 |
|---|---|---|---|---|
| Goal records with patient agreement recorded | 100% | Quarterly | 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-002 | Rehabilitation goals and expectations record | 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)