Standards › Standard 42 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · AFT-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 42.3
At a glance
- Each high-risk patient is identified before discharge (AFT-REG-001).
- Each high-risk patient is contacted within the defined time after discharge.
- Each contact is recorded.
- Any problem is escalated to the responsible clinician the same day.
- Stop and get help straight away if: a high-risk patient is discharged and not contacted within the defined time.
1. Purpose
To catch problems early in patients most likely to be harmed after discharge (42.3).
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
Some patients are at high risk after discharge, such as those living alone or with many conditions. A call within a set time catches problems before they become emergencies.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Discharge lead nurse | Identifies high-risk patients and arranges the contact | Clinical director |
| Contact nurse | Makes the contact and escalates problems | Discharge lead nurse |
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. Identify.
- Identify high-risk patients before discharge and add them to the contact register (AFT-REG-001).
Key point: Identified.
Step 2. Contact.
- Contact each high-risk patient within the defined time after discharge.
Key point: Contacted.
Step 3. Escalate.
- Escalate any problem to the responsible clinician the same day and record it.
Key point: Escalated.
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 |
|---|---|---|---|---|
| High-risk patients contacted within the defined time | 100% | Monthly | Discharge lead nurse | 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 |
|---|---|---|
| AFT-REG-001 | Post-discharge contact register | Register |
| HOS-REG-003 | Post-discharge follow-up register (existing) | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Global Patient Safety Action Plan 2021–2030 for transitions of care, the WHO Emergency Care Systems framework for urgent help, and the ASF Hospital standard for discharge and aftercare. |
| 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)