Standards › Standard 36 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · ED-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 36.5
At a glance
- Each patient who leaves before assessment is recorded in the register (ED-REG-002).
- The department makes reasonable attempts to follow up each patient by phone or letter.
- The attempts and their dates are recorded.
- The rate and reasons are reviewed at the set interval.
- Stop and get help straight away if: a patient leaves before assessment and is not recorded.
1. Purpose
To make sure patients who leave before being seen are known about and followed up (36.5).
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
Patients who leave before they are seen may be seriously unwell, and the department must know who they are to follow them up. Recording and following up those patients is part of safe care.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Nurse in charge of the shift | Records each departure and starts follow-up | Emergency department lead |
| Emergency department lead | Reviews the rate and reasons | 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. Record.
- Record each patient who leaves before assessment, with the time and any reason given (ED-REG-002).
Key point: Recorded.
Step 2. Follow up.
- Make reasonable attempts to follow up by phone or letter and record each attempt.
Key point: Followed up.
Step 3. Review.
- Review the rate and the reasons at the set interval.
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 |
|---|---|---|---|---|
| Departures recorded with follow-up attempts | 100% | Monthly | Emergency department lead | 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 |
|---|---|---|
| ED-REG-002 | Left-before-assessment register | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Emergency Care Systems framework and the Emergency Triage Assessment and Treatment guidance, the WHO Global Patient Safety Action Plan 2021–2030 for handover, and the ASF Hospital standard for senior clinician responsibility. |
| 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)