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International Accreditation of Healthcare Facilities

Standards › Standard S6 › Policies

Policy · PTR-POL-002 · Version 1.0 · Approved by the ASF Expert Committee

Supports: System S6 (Patient transfers and referrals), criterion S6.44, S6.42, S6.43, S6.35

At a glance

  • Insurance covers every segment, including air and the escort, and is confirmed before departure.
  • The escort’s right to practise in the country of care is checked and documented.
  • Medicines and equipment crossing a border have the paperwork of both countries.
  • Patient data is shared under the data protection rules of both countries.
  • Stop and get help straight away if: a transfer departs with a segment uninsured, an escort who is not permitted to practise, or medicines with no border paperwork.

1. Purpose

To keep cross-border and multi-segment transfers lawful, insured and data safe (S6.44, S6.42, S6.43, S6.35).

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 patient moved across a border carries information that must be readable by the receiving team and must be protected. Records in a language the receiving team cannot read, or shared without data protection, cause harm and break the law.

5. Responsibilities

Role Responsibility Competence
Accountable manager Owns the policy and the insurance check Management
Dispatch lead Confirms cover and paperwork before departure Trained dispatcher

6. Materials and equipment

Item Requirement Condition
Records and forms named in this document Current version Checked before use

7. Safety

8. Before you start

9. Procedure

Step 1. Confirm insurance.

  • Confirm cover for each segment and the escort in writing.
  • Record the confirmation on the transfer plan.

Key point: No cover, no departure.

Step 2. Check practice rights.

  • Check the escort doctor and nurse can practise in the country of care, or that the arrangement permitting it is documented.

Key point: Permission is written, not assumed.

Step 3. Border paperwork.

  • Complete PTR-FRM-001 for medicines and equipment.
  • Keep the paperwork with the goods.

Key point: Paper travels with the goods.

10. Decision points

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

13. Monitoring

Measure Target Frequency Owner If not met
Transfers with insurance confirmed before departure 100% Monthly Dispatch lead Escalate to accountable manager
Cross-border transfers with complete paperwork 100% Monthly Dispatch lead Escalate to accountable manager

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

16. Related documents

ID Title Use
PTR-FRM-001 Cross-border medicines and equipment declaration Form
HOS-POL-001 Medicines management policy Policy

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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