WTG-POL-002: Patient questions and teach-back

Policy · WTG-POL-002 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 45.5

At a glance

Patients can ask questions at any point, in any setting.
Teach-back is used for key decisions: diagnosis, treatment, medicines and discharge (WTG-FRM-003).
Questions and feedback are recorded and answered within the set time.
Consent for significant care is given with the information needed to decide (CON-SOP-001).
Stop and get help straight away if: a key decision is made without a teach-back check.

1. Purpose

To make sure patients can ask questions and understand the answers, and that understanding is checked for key decisions (45.5).

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 cannot ask questions, or who do not get answers they understand, cannot take part in their care. Making it possible to ask at any point keeps the patient involved.

5. Responsibilities

Role	Responsibility	Competence
Service lead	Makes sure staff invite and answer questions	Service director
Every clinician	Uses teach-back for each key decision and records it	Service lead

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. Invite.

Tell the patient they may ask questions at any point.

Key point: Invited.

Step 2. Check.

Ask the patient to say in their own words what was decided (WTG-FRM-003).
Correct and repeat the explanation where the patient is unsure.

Key point: Checked.

Step 3. Record and answer.

Record each question and its answer.
Answer any complaint or feedback under INC-POL-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
Key decisions with a teach-back record	100%	Monthly	Service lead	Escalate to the service director
Questions answered within the set time	95%	Monthly	Service lead	Review the staffing and the process

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
WTG-FRM-003	Teach-back record for key decisions	Record
CON-SOP-001	Informed consent before significant care (existing, reused)	SOP
INC-POL-002	Complaints and feedback (existing, reused)	Policy

17. Evidence

Reference	Note
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

Reception & Information: The First Ten Minutes (H-02)

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)

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