Standards › Standard S1 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · HOS-SOP-010 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S1 (Hospital), criterion S1.10
At a glance
- Write an aftercare plan for every discharged patient.
- Explain it and check understanding with the patient (teach-back).
- Send the plan to the next provider on the day of discharge.
- Give the patient a copy.
- Stop and get help straight away if: a patient leaves the hospital with no written aftercare plan.
1. Purpose
To make sure every patient leaves with a clear, written plan that is understood and reaches the next provider (S1.10).
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
Patients who leave without a written plan often return or harm themselves. A written, explained plan sent to the next provider keeps the care going.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Discharging clinician | Writes and explains the plan | Doctor or nurse |
| Ward clerk or nurse | Sends the plan to the next provider | Administrative |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Discharge aftercare plan (HOS-FRM-008) | Current | Printed on the ward |
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. Write the plan.
- Write the diagnosis, the medicines, the follow-up and the warning signs.
Key point: The plan is written before the patient leaves.
Step 2. Explain.
- Explain the plan to the patient and any carer.
- Ask them to say back the key points (teach-back).
Key point: Teach-back shows understanding.
Step 3. Send.
- Send the plan to the next provider on the day.
- Record the date and the receiver.
Key point: The next provider needs it on day one.
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 |
|---|---|---|---|---|
| Discharges with written plan | 100% | Monthly | Ward manager | Escalate to clinical director |
| Plans sent on the day | At least 70% | Monthly | Ward manager | Escalate to clinical 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 |
|---|---|---|
| HOS-FRM-008 | Discharge aftercare plan | Plan form |
| HOS-SOP-011 | Post-discharge follow-up | Follow-up after the plan |
17. Evidence
| Reference | Note |
|---|---|
| E-007 | WHO Nine patient safety solutions (2007): communication at transfers. |
| 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)
- World Health Organization (2007). Nine patient safety solutions, including correct patient identification. Geneva: WHO. Open source (E-007)