Standards › Standard S5 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · AMT-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S5 (Ambulance and patient transport), criterion S5.4
At a glance
- Send a patient only to a receiver with a written agreement.
- Agree the handover point, the acceptance process and the escalation contact.
- Confirm acceptance before the vehicle leaves.
- Record the receiver’s name and the time of acceptance.
- Stop and get help straight away if: a patient is sent to a receiver with no written agreement, or without acceptance confirmed.
1. Purpose
To make sure each receiving service has agreed where and to whom the patient is handed over (S5.4).
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
Most harm in transfer happens at the handover. If the receiving hospital has not agreed where and to whom the patient is handed over, the patient can wait on a pavement or in a corridor with no one responsible.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Dispatch lead | Holds the agreements and confirms acceptance | Trained dispatcher |
| Clinical lead | Agrees the escalation contacts with each receiver | Clinician |
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. Check the agreement.
- Check the receiving service is on the register of agreements (AMT-REG-002).
- If there is no agreement, do not send the patient there.
Key point: No agreement, no transfer.
Step 2. Confirm acceptance.
- Call the receiver before the vehicle leaves.
- Record the name of the person who accepts the patient and the time.
Key point: Acceptance is confirmed, not assumed.
Step 3. Escalate.
- If the receiver cannot accept, use the escalation contact in the agreement.
- Record the change and the reason in the log.
Key point: The escalation contact is written down.
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 |
|---|---|---|---|---|
| Transfers to receivers with a written agreement | 100% | Monthly | Dispatch lead | Escalate to clinical lead |
| Acceptance confirmed before departure | 100% | Monthly | Dispatch lead | Escalate to clinical lead |
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 |
|---|---|---|
| AMT-REG-002 | Receiving service agreements register | Register |
| AMT-SOP-001 | Transfer logging and handover | Log |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | ASF Expert Committee consensus. |
| 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 |
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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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