PHC-SOP-003: Referral criteria and referral tracking

Standards › Standard S3 › Standard operating procedures (SOPs)

Standard operating procedure (SOP) · PHC-SOP-003 · Version 1.0 · Approved by the ASF Expert Committee

Supports: System S3 (Primary care practice), criterion S3.4

At a glance

Refer using the written criteria for each specialty.
Send each referral in writing with the reason.
Track every referral until the outcome comes back.
Urgent referrals go the same day by the urgent route.
Stop and get help straight away if: an urgent case has no same-day route, or a referral has no outcome after the set time.

1. Purpose

To make sure referrals are appropriate, reach the right place, and are followed to an outcome (S3.4).

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

Referrals that are sent but never tracked lose patients. Each referral needs clear criteria, a same-day route for urgent cases, and a record of the outcome.

5. Responsibilities

Role	Responsibility	Competence
Clinician	Refers using the criteria; reviews outcomes	Doctor or nurse practitioner
Referral coordinator	Tracks each referral and chases outcomes	Administrative

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. Check the criteria.

Check the referral criteria for the specialty.

Key point: Refer for a reason.

Step 2. Refer.

Send the referral in writing with the reason and the findings.
Record it on PHC-REG-002.

Key point: Written and recorded.

Step 3. Track.

Chase each referral at the set time.
Record the outcome when it comes back.

Key point: A referral is not closed until the outcome is back.

Step 4. Urgent.

Use the same-day urgent route for urgent cases.
Record the time of the call.

Key point: Urgent is same day.

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 with outcome recorded within the set time	At least 70%	Monthly	Clinical lead	Escalate to chief executive
Urgent referrals made the same day	100%	Monthly	Clinical lead	Escalate to chief executive

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	Register
PHC-SOP-001	Routing conditions not managed	Routes

17. Evidence

Reference	Note
E-009	ASF Expert Committee consensus. Chase times to be confirmed.
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)

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