One procedure covering the whole service user journey, from the moment a person first approaches the organization to the moment they are discharged. ISO 7101 has no clause called intake, triage or admission — the obligation is assembled across the definition at 3.28, access to care at 5.5, service user communication at 7.4.2 and provision of services at 8.9. Nothing in the standard tells you to join them. This file joins them, in the order the obligations actually arise.
01 · The record starts at registration
Intake procedures begin where the patient administration system begins, because that is where a record first exists. Under 3.28 the obligation began earlier. Clause 7.4.2 b) requires enquiries to be handled including any actions taken — and the enquiry that ended in a redirection is precisely the one nothing downstream needs, so nothing downstream keeps it. MSI has not yet seen an intake process that captured it by default.
02 · The wait time is measured over the wrong population
A stable median wait reaching management review reads as an access result. It is a throughput result. The mechanism by which access fails — people not getting in — deletes them from the measure, so a worsening catchment problem shows up as a flat number. The correction is one line on the report, and it is usually the line that opens the conversation.
03 · Consent is evidenced by a signature
Clause 8.9 i) requires informed consent obtained in such a manner that the service user clearly understands. A signature records that a form was presented. It does not evidence understanding, which is the thing the clause actually asks for — and 8.10.5 f) names the moments where it matters most: before procedures requiring consent, at care transitions, and in communication about medication.
Every appendix, form and worked example is part of the document. Nothing is sold separately.
Healthcare organizations implementing or maintaining ISO 7101 — hospitals, outpatient clinics, day-surgery units, community and speciality services — and the quality leads who have to produce an accessibility input for management review that says something. Also for consultants who need one document covering the journey rather than four covering fragments of it.
Not sure where you stand? The free Access and Entry Maturity Check scores your process across eight elements in about ten minutes, and your score appears without entering anything.
No, and they are built to work together. Leadership and Governance covers access to care at 5.5 as a governance obligation — whether leadership is accountable for equitable access at all. This file produces the record that lets them see it. Buy the leadership file if your question is who owns access; buy this one if your question is what actually happens when someone calls.
An admissions procedure starts at admission. This starts at the point ISO 7101 says your obligation starts, which is earlier — at the declared mandate and the first approach. The sections from registration forward may duplicate what you have. Sections 6.1 through 6.3 and Appendix A almost certainly do not, and they are where the accessibility input at 9.3.2 g) comes from.
It means logging every approach seeking care, with the action taken and a reason drawn from a fixed list. Appendix A is deliberately built to hold every enquiry rather than only the declined ones — a log containing only refusals becomes a complaints record and attracts the defensiveness that goes with one. Logging everything makes a decline a row among rows, which is the only version that survives a busy front desk.
Both, deliberately. It is written as a filled-in worked example so you can see what each element looks like when done properly, with bracketed placeholders wherever a value is genuinely yours to set. You are editing a working document rather than filling in a hollow outline.
Editable Microsoft Word (.docx). The license permits the buying organization to adapt and adopt it across its own sites and issue it to employees, contractors, auditors, regulators and accreditation bodies, and permits consultants to adapt it for engagements they deliver.
A procedure is not assessed; an organization is. What this gives you is a procedure that addresses every obligation across the journey with a named owner and a named record, and a cross-reference that shows an assessor where each one lives. Conformity is demonstrated by implementation and evidence. Unfilled placeholders are unmet requirements, so fill them.
That is fine. Call MSI at 760-434-9141 and ask for Diana, and we will raise an invoice.
