Standards › Standard S1 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · HOS-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S1 (Hospital), criterion S1.2
At a glance
- Record vital signs for every inpatient at the frequency set for their level.
- Raise the frequency when the patient worsens.
- Act on each early warning score at the level it triggers.
- Call the senior clinician at the trigger level, and document the response.
- Stop and get help straight away if: a patient has a high early warning score and no senior clinician has been called.
1. Purpose
To find patients who are getting worse early, and to respond in a set way at each score (S1.2). The early warning score (NEWS2 or the equivalent in use) is the trigger.
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 |
|---|---|
| Early warning score | A score from the vital signs that shows how sick a patient is |
| Trigger level | The score at which a set response is required |
4. Background
Most deaths on a ward were preceded by hours of warning signs. A score that is recorded but leads to no response protects no one.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Nurse in charge | Sets and checks the observation frequency on the ward | Competent in scoring |
| Registered nurse | Records observations and scores; calls for help at the trigger | Trained in the score |
| Senior clinician | Reviews the patient at the trigger level | Senior medical or nursing decision maker |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Observation chart with the early warning score | Current | Printed on the chart |
| Calibrated thermometer, pulse oximeter, sphygmomanometer | Within the calibration date | Checked monthly |
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. Observe at the set frequency.
- Record vital signs at the time set for the patient level.
Key point: Missed observations are a finding.
Step 2. Score.
- Calculate the early warning score from the vital signs.
- Mark the score on the chart.
Key point: Score every set.
Step 3. Respond at the trigger.
- Low score: continue the set frequency.
- Medium score: increase the frequency and call the nurse in charge.
- High score: call the senior clinician now.
Key point: The response is set by the score, not by a judgement made later.
Step 4. Record the response.
- Write the response, the person called and the time.
Key point: A response not written did not happen for audit.
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 |
|---|---|---|---|---|
| Scheduled observations recorded on time | At least 70% | Monthly | Nurse in charge | Escalate to clinical director |
| High scores with senior review within 30 minutes | 100% | Monthly | Duty clinical lead | Escalate to chief executive |
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-FRM-002 | Observation and early warning chart | Chart used in steps 1 and 2 |
| HOS-SOP-003 | Sepsis recognition and antibiotic timing | Sepsis is one cause of deterioration |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Score-based response per the National Early Warning Score guidance (RCP, 2017); local score set by the ASF Expert Committee by the Committee. |
| 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)