Standards › Standard 30 › Standard operating procedures (SOPs)
Procedure · FW-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 30.7
At a glance
- Every member completes a health screen before first exercise (FW-FRM-005).
- Any risk found is acted on before exercise begins: clearance, a modified plan, or referral.
- The screen and the action are recorded.
- Members are re-screened when their health changes.
- Stop and get help straight away if: a member with a known heart condition starts high-intensity training with no screen.
1. Purpose
To identify health risks before a member first exercises (30.7).
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
Some people who start exercise have a heart or other condition that exercise can make dangerous. A health screen before the first session finds them before they collapse.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Fitness service lead | Owns the screening rule | Clinician or manager |
| Front-of-house or instructor | Completes the screen with the member | 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. Screen.
- Complete the screen on FW-FRM-005 before the first session.
Key point: Screened.
Step 2. Act on risk.
- Act on any risk before exercise: clearance, modified plan or referral.
Key point: Acted.
Step 3. Re-screen.
- Re-screen when the member’s health changes.
Key point: Re-screened.
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 |
|---|---|---|---|---|
| New members with a screen before first exercise | 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 |
|---|---|---|
| FW-FRM-005 | Pre-participation screening form | Record |
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)