Standards › Standard S3 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · PHC-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S3 (Primary care practice), criterion S3.2
At a glance
- When a condition is not on the managed list, follow the route for it.
- Refer in writing with the reason.
- Give the patient the referral details.
- Record the route taken.
- Stop and get help straight away if: a patient with a condition the practice does not manage is sent away with no referral.
1. Purpose
To make sure patients with conditions outside the practice’s list are referred correctly and safely (S3.2).
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
A practice that does not know which conditions it manages will send everything elsewhere, or manage things it cannot. A written list of managed conditions and a clear referral route keep first-contact care safe.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinician | Decides on the route and writes the referral | Doctor or nurse practitioner |
| Reception | Sends the referral and tells the patient | Trained |
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. Decide.
- Check the managed list.
- If not on the list, choose the route written for the condition.
Key point: The list decides.
Step 2. Refer.
- Write the referral with the reason and the findings.
- Send it the same day.
Key point: The receiver needs the reason.
Step 3. Tell the patient and record.
- Tell the patient where they are going and what to do.
- Record the route and date.
Key point: The patient knows where next.
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 outside the list with route recorded | 100% | Monthly | Clinical lead | Escalate to clinical lead |
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-POL-002 | Managed conditions and first-contact care list | List |
| PHC-REG-002 | Referral tracking register | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | ASF Expert Committee consensus. |
| 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)