Standards › Standard S1 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · HOS-SOP-011 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S1 (Hospital), criterion S1.11
At a glance
- Identify higher-risk patients at discharge using the set criteria.
- Book a follow-up call or visit for each one.
- Record each follow-up and its outcome.
- Act on every problem found the same day.
- Stop and get help straight away if: a higher-risk patient has not been contacted within the set time after discharge.
1. Purpose
To check on patients at higher risk after they leave, so that problems are found early (S1.11).
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 patients are more likely to deteriorate after going home. A defined follow-up, with the outcome recorded, finds them in time.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Discharging clinician | Identifies higher-risk patients | Doctor or nurse |
| Follow-up nurse | Makes the follow-up and records the outcome | Trained |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Post-discharge follow-up register (HOS-REG-003) | Current | Updated daily |
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. Identify.
- Use the criteria for higher risk at discharge, and mark the patient.
Key point: Mark at discharge, not later.
Step 2. Contact.
- Call or visit within the time set.
- Check the key points of the aftercare plan.
Key point: The call is short and specific.
Step 3. Record and act.
- Write the outcome on the register.
- Act on each problem the same day, and tell the clinician.
Key point: A problem found but not acted on is a failure.
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 |
|---|---|---|---|---|
| Higher-risk patients with follow-up | At least 70% | Monthly | Ward manager | Escalate to clinical director |
| Problems with action the same day | 100% | 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-REG-003 | Post-discharge follow-up register | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Higher-risk criteria set by the ASF Expert Committee by the clinical director. |
| 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
No e-learning course is linked to this document yet.
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)