Standards › Standard 30 › Standard operating procedures (SOPs)
Procedure · FW-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 30.5
At a glance
- Instructors are trained to recognise warning signs: pain beyond expected levels, swelling and abnormal movement compensation.
- When a sign appears, the activity is stopped or modified at once.
- The member is referred back to medical care when a sign persists or is severe.
- Each stop is recorded.
- Stop and get help straight away if: a member continues to exercise with sharp pain and no one stops them.
1. Purpose
To stop post-injury activity safely when warning signs appear (30.5).
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
Members sometimes push through pain that is a warning sign. Staff who recognise the warning signs and stop the exercise prevent a new injury.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Fitness service lead | Owns the stop protocol and training | Clinician or manager |
| Instructor | Recognises signs and stops the activity | Staff |
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. Watch.
- Observe each member for the warning signs during the session.
Key point: Observed.
Step 2. Stop or modify.
- Stop or modify the activity at once when a sign appears.
Key point: Stopped.
Step 3. Refer and record.
- Refer back to medical care if the sign persists, and record the stop.
Key point: Referred.
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 |
|---|---|---|---|---|
| Sessions with a recorded stop when a warning sign appears | 100% | Monthly | Fitness service lead | Escalate to medical 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 |
|---|---|---|
| INC-POL-001 | Incident reporting and management (existing, reused) | Policy |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO guidance on digital health and data protection, the American College of Sports Medicine Guidelines for Exercise Testing and Prescription (11th ed., 2021), and the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care (2020). |
| 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)