URG-POL-002: Published limits of service

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

Supports: 21.2

At a glance

The service publishes the conditions it can treat and the conditions it cannot treat (URG-FRM-002 route).
The limits show the date they were last reviewed.
A patient with a condition the service cannot manage is given the route at once, not kept for hours.
The limits are checked against the staff and equipment at each review.
Stop and get help straight away if: a patient with a condition the service cannot manage is kept for hours.

1. Purpose

To make clear what the service can and cannot treat, and the route for those it cannot (21.2).

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

Patients who come to an urgent care service need to know whether it can treat them. A service that accepts patients it cannot treat delays them and puts them at risk; one that turns them away without a route leaves them stranded.

5. Responsibilities

Role	Responsibility	Competence
Service manager	Publishes and reviews the limits	Manager
Clinical lead	Confirms the limits against capability	Clinician

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. Publish the limits.

Publish the conditions the service can and cannot treat, with the date.

Key point: Published.

Step 2. Give the route.

For a condition the service cannot treat, give the route at once and record it (URG-FRM-002).

Key point: Route given.

Step 3. Review.

Review the limits against staff and equipment at the set interval.

Key point: Reviewed.

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
Patients given a route at once when the condition is outside the service	100%	Monthly	Service manager	Escalate to medical 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
URG-FRM-002	Route for conditions outside the service	Record

17. Evidence

Reference	Note
E-009	Based on the WHO Emergency triage, assessment and treatment (ETAT) manual (2005) and the WHO Emergency care systems for universal health coverage (2016).
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

No e-learning course is linked to this document yet.

Planned course: Defining and publishing limits of urgent care. New course planned.

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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