Standards › Standard 41 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · TRM-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 41.3
At a glance
- Warning signs are screened for at each visit (TRM-FRM-002).
- A patient with a warning sign is referred to conventional care without delay.
- Complementary treatment does not replace a conventional diagnosis or treatment that is needed.
- Each referral is recorded and followed up.
- Stop and get help straight away if: a patient with a warning sign is kept on complementary treatment alone.
1. Purpose
To make sure serious conditions are found and treated conventionally, and not delayed (41.3).
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 with a serious illness who uses only traditional treatment may be harmed by delay. A service must refer the patient to conventional care when it is needed.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Practitioner | Screens for warning signs and refers | Service lead |
| Service lead | Owns the referral pathway and follow-up | Clinical director |
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. Screen.
- Screen each visit for the warning signs the service lists (TRM-FRM-002).
Key point: Screened.
Step 2. Refer.
- Refer any patient with a warning sign to conventional care without delay.
Key point: Referred.
Step 3. Follow up.
- Follow up each referral and record the outcome.
Key point: Followed up.
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 |
|---|---|---|---|---|
| Warning signs with referral within the set time | 100% | Monthly | 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-FRM-002 | Referral and warning sign record | Record |
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
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)