Standards › Standard 42 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · AFT-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 42.4
At a glance
- Each patient is given written warning signs that need urgent help (AFT-FRM-002).
- Each patient is given a route to urgent help at any hour, by phone and in person.
- The patient is asked to repeat the warning signs back.
- The leaflet is in the patient’s language.
- Stop and get help straight away if: a patient is discharged with no written warning signs or no out-of-hours route.
1. Purpose
To make sure a patient knows when to seek urgent help and how to reach it at any time (42.4).
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 do not know which symptoms need urgent help may wait too long. Written warning signs, with a route to get help, let them act in time.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Discharge lead nurse | Owns the leaflet and the out-of-hours route | Clinical director |
| Discharging clinician | Gives the leaflet and checks understanding | 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. Give.
- Give the written warning signs and the out-of-hours route at discharge.
Key point: Given.
Step 2. Check.
- Ask the patient to repeat the warning signs back and record the check (AFT-FRM-002).
Key point: Checked.
Step 3. Confirm route.
- Confirm the phone number and in-person route are on the leaflet and current.
Key point: Confirmed.
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 warning signs and route given | 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-FRM-002 | Warning signs and urgent help record | Record |
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)