Standards › Standard S6 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · PTR-SOP-010 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S6 (Patient transfers and referrals), criterion S6.41
At a glance
- Speak to each patient in a language they understand.
- Use a qualified interpreter when the patient or family needs one.
- Record the language and the interpreter used.
- Records that travel to another country are in a language the receiver can read.
- Stop and get help straight away if: a patient cannot understand the crew about the transfer and no interpreter is used.
1. Purpose
To make sure patients understand their transfer and that the receiving team can read the record (S6.41, 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 who cannot understand the crew cannot give consent, report pain or follow instructions. A way to communicate in the patient’s language is part of safe transfer.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Crew lead | Arranges the interpreter | Trained crew |
| Dispatch lead | Books the interpreter and records the language | Trained dispatcher |
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. Identify language.
- Ask the patient and family which language they understand best.
- Record it on the transfer log.
Key point: Ask first.
Step 2. Use an interpreter.
- Book a qualified interpreter when needed, by phone if necessary.
- Record the interpreter’s name or reference.
Key point: No family as interpreter for clinical information.
Step 3. Translate the record.
- Provide the key handover information in the receiver’s language.
Key point: The receiver can read it.
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 |
|---|---|---|---|---|
| Transfers with language recorded | 100% | Monthly | Dispatch lead | Escalate to clinical lead |
| Patients needing an interpreter with one used | 100% | Monthly | Crew 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 |
|---|---|---|
| HOS-SOP-013 | Vulnerable patients and safeguarding | Vulnerability |
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)
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