Standards › Standard 38 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · SUB-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 38.5
At a glance
- Discharge or transfer is planned in advance (SUB-FRM-003).
- Each person is referred to community support.
- A relapse plan is agreed with the person and recorded.
- The plan is shared with the receiving service with consent.
- Stop and get help straight away if: a person is discharged with no community referral and no relapse plan.
1. Purpose
To keep people connected to support after treatment ends, and prepared for a relapse (38.5).
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
Leaving treatment without a link to community support is a common reason for relapse. A planned discharge with referrals keeps the person connected after the service ends.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead for addiction services | Owns the discharge standard | Clinical director |
| Keyworker | Plans the discharge and agrees the relapse plan | Clinical lead for addiction services |
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. Plan.
- Start the discharge plan early and record the date.
Key point: Planned.
Step 2. Refer.
- Refer the person to community support and record the referral (PHC-SOP-003).
Key point: Referred.
Step 3. Agree relapse plan.
- Agree the relapse plan with the person and record it (SUB-FRM-003).
Key point: Agreed.
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 |
|---|---|---|---|---|
| Discharges with community referral and relapse plan | 100% | Monthly | Clinical lead for addiction services | 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 |
|---|---|---|
| SUB-FRM-003 | Discharge and relapse plan record | Record |
| PHC-SOP-003 | Referral criteria and referral tracking (existing) | Procedure |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO guidelines for the psychosocially assisted pharmacological treatment of opioid dependence (2009), the WHO Guidelines on HIV and harm reduction for people who inject drugs, and the ASF Ambulatory standard for addiction services. |
| 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
- Narcology & Addiction Treatment (AMB-21)
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)