Standards › Standard 25 › Standard operating procedures (SOPs)
Procedure · HMG-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 25.4
At a glance
- Engage the legal, education, employment, housing and social services relevant to each patient.
- Record each referral on PHC-REG-002 and track it to a result.
- Include migration and displacement context in each handover.
- Follow up any referral that does not reach its service.
- Stop and get help straight away if: a patient with no housing returns to the same clinic with the same problem.
1. Purpose
To connect health care with the social services that affect the patient’s health (25.4).
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
Health problems in migrant and displaced people are often driven by housing, work, legal status and schooling. A clinic that works with those services can address the cause, not only the symptom.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Social work or navigation lead | Owns the referral pathway | 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. Refer.
- Refer the patient to the relevant service and record it on PHC-REG-002.
Key point: Referred.
Step 2. Hand over.
- Include the migration and displacement context in the handover.
Key point: Handed over.
Step 3. Track.
- Track each referral to a result and follow up any that is not reached.
Key point: Tracked.
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 |
|---|---|---|---|---|
| Referrals tracked to a result | 90% | Monthly | Social work or navigation 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 |
|---|---|---|
| PHC-REG-002 | Referral tracking register (existing, reused) | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO and IOM Global Competency Standards for Refugee and Migrant Health and the WHO mhGAP Intervention Guide (2019). |
| 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)