Standards › Standard 28 › Standard operating procedures (SOPs)
Procedure · LTC-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 28.2
At a glance
- Therapy goals are shared with the nursing and care team at each review (CLN-FRM-003).
- Daily practice, such as transfers and walking, follows the therapy plan.
- A conflict between therapy and daily practice is resolved at the review, and recorded.
- The resident and family are told the agreed approach.
- Stop and get help straight away if: therapy asks for independent walking and nursing transfers the resident by hoist every time.
1. Purpose
To make sure therapy and daily care work toward the same goals (28.2).
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
In long-term care the therapist and the daily nursing team see the resident at different times. If their goals differ, the resident gets mixed messages every day.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead for long-term care | Owns the coordination rule | Clinician or manager |
| Therapist and nurse in charge | Agree and record the shared approach | Clinician |
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. Share goals.
- Share the therapy goals with the nursing and care team, and record them in the individual care plan.
Key point: Shared.
Step 2. Align practice.
- Agree how each daily task (transfer, walking) will follow the therapy plan.
Key point: Aligned.
Step 3. Resolve conflict.
- Resolve any conflict at the review and record the agreed approach.
Key point: Resolved.
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 |
|---|---|---|---|---|
| Residents with therapy and care goals shared at review | 95% | Monthly | Clinical lead for long-term care | 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 |
|---|---|---|
| CLN-FRM-003 | Individual care plan (existing, reused) | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Global strategy and action plan on ageing and health 2016-2030, WHO Integrated care for older people (ICOPE) guidelines (2017), and WHO guidance on digital and AI governance. |
| 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)