TRM-POL-001: Practitioner qualification and registration

Policy · TRM-POL-001 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 41.1

At a glance

Every practitioner is registered with the regulator for the practice they offer (TRM-REG-001).
Registration is checked before the practitioner starts and at the set interval.
Treatment is limited to the scope the registration allows.
A practitioner whose registration lapses stops treating patients until it is renewed.
Stop and get help straight away if: a practitioner treats patients with no registration or outside their registered scope.

1. Purpose

To make sure only registered and qualified practitioners deliver treatment, and only within their scope (41.1).

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 practitioner who is not qualified or registered may harm patients. Verifying the qualification and registration of every practitioner protects the public.

5. Responsibilities

Role	Responsibility	Competence
Service lead	Owns the register and the scope rules	Clinical director
Each practitioner	Keeps registration current and works within scope	Service lead

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. Verify.

Check each practitioner against the regulator’s register before they start (TRM-REG-001).

Key point: Verified.

Step 2. Limit.

Set the scope of practice for each practitioner from the registration.

Key point: Limited.

Step 3. Renew.

Check registration at the set interval and stop any lapsed practitioner at once.

Key point: Renewed.

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
Practitioners with current registration in scope	100%	Quarterly	Service lead	Escalate to the clinical director

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
TRM-REG-001	Practitioner registration register	Register
STF-FRM-001	Staff verification register (existing)	Register

17. Evidence

Reference	Note
E-009	Based on the WHO Traditional Medicine Strategy 2014–2023, the WHO guidance on substandard and falsified medical products, and the ASF Hospital standard for informed consent and incident reporting.
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

E-learning for this document

Credentialing, Competence and the Training Matrix (T-14)

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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