Standards › Standard S3 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · PHC-SOP-004 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S3 (Primary care practice), criterion S3.5
At a glance
- Every patient with a chronic condition has a written care plan.
- Recall each patient for review at the interval in the plan.
- Review clinical measures against the agreed targets.
- Act when a target is missed.
- Stop and get help straight away if: a patient with a chronic condition has no care plan or no review in the last 12 months.
1. Purpose
To catch chronic conditions getting worse between visits (S3.5).
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
Chronic conditions worsen quietly between visits. A written plan, a recall system and regular review against targets catch the change before it becomes an emergency.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinician | Writes and reviews the care plan | Doctor or nurse practitioner |
| Recall administrator | Runs recall and records the outcome | Administrative |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Chronic care plan (PHC-FRM-002) | Current | On the record |
| Recall register (PHC-REG-003) | Current | Updated weekly |
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. Plan.
- Write the care plan with the patient, with targets and the review interval.
Key point: The plan has a target.
Step 2. Recall.
- Recall the patient at the interval set in the plan.
Key point: Recall is how the plan works.
Step 3. Review and act.
- Review the measures against the targets.
- Change the plan where a target is missed.
Key point: A missed target is an action, not a note.
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 |
|---|---|---|---|---|
| Chronic patients with a current plan | At least 70% | Quarterly | Clinical lead | Escalate to clinical lead |
| Recalls completed on time | At least 70% | Monthly | Practice manager | 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-FRM-002 | Chronic care plan | Plan form |
| PHC-REG-003 | Recall register | Recall record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | ASF Expert Committee consensus. Targets to follow current national guidance. |
| 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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