Standards › Standard 55 › Standard operating procedures (SOPs)
SOP · PLS-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 55.5
At a glance
- Each patient has recovery monitoring, and is discharged only when the discharge criteria are met (DAY-FRM-002).
- Each patient has an escort and written advice on what to watch for.
- Each patient is contacted within the set time after discharge (AFT-REG-001).
- Complications are followed up and recorded (PLS-FRM-003).
- Stop and get help straight away if: a patient is discharged without an escort or written advice, or a complication is not followed up.
1. Purpose
To make sure patients recover safely, go home with an escort and advice, and are followed up for complications (55.5).
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
To make sure patients recover safely, go home with an escort and advice, and are followed up for complications (55.5).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Surgeon | Sets the discharge criteria and the follow-up plan | Clinical lead |
| Recovery nurse | Monitors recovery and gives the written advice | Surgeon |
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. Monitor.
- Monitor recovery until the discharge criteria are met (DAY-FRM-002).
Key point: Monitored.
Step 2. Discharge.
- Discharge with an escort and written advice on complications.
Key point: Discharged.
Step 3. Follow up.
- Contact the patient within the set time, and record any complication (PLS-FRM-003).
Key point: Followed.
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 escort and written advice | 100% | Monthly | Clinical lead | Escalate to the surgeon |
| Patients contacted within the set time | 95% | Monthly | Clinical lead | Contact the remaining patients at once |
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 |
|---|---|---|
| PLS-FRM-003 | Discharge and complication follow-up record | Record |
| AFT-REG-001 | Post-discharge contact register (existing, reused) | Register |
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
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)