Standards › Standard 56 › Standard operating procedures (SOPs)
SOP · CAR-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 56.5
At a glance
- Each patient leaves with a written follow-up and risk reduction plan (CAR-FRM-003).
- The follow-up appointment is booked and confirmed before the patient leaves.
- Advice on risk factors (smoking, weight, blood pressure, activity) is given and recorded.
- Devices and antithrombotic therapy are reviewed at the set interval (ANT-REG-001).
- Stop and get help straight away if: a patient leaves a cardiac procedure with no written plan or no booked follow-up.
1. Purpose
To make sure cardiac patients leave with a plan for follow-up and risk reduction (56.5).
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 cardiac patients leave with a plan for follow-up and risk reduction (56.5).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Cardiologist | Writes the plan and sets the follow-up | Clinical lead |
| Cardiac nurse | Gives the advice and books the follow-up | Cardiologist |
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. Plan.
- Write the follow-up and risk reduction plan with the patient (CAR-FRM-003).
Key point: Planned.
Step 2. Book.
- Book and confirm the follow-up appointment before the patient leaves.
Key point: Booked.
Step 3. Review.
- Review devices and antithrombotic therapy at the set interval.
Key point: Reviewed.
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 |
|---|---|---|---|---|
| Patients with a written plan and booked follow-up at discharge | 100% | Monthly | Clinical lead | Book before the patient leaves |
| Follow-ups attended or chased | 95% | Monthly | Clinical lead | Contact the patient within 7 days |
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 |
|---|---|---|
| CAR-FRM-003 | Cardiac follow-up and risk reduction plan record | Record |
| ANT-REG-001 | Anticoagulant use and reversal 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
- Cardiology & Cardiac Catheterization (AMB-14)
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)