Standards › Standard 6 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · DAY-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 6.3
At a glance
- Each patient is monitored in the recovery area by trained staff.
- Monitoring continues until the written discharge criteria are met.
- Vital signs, pain, nausea and consciousness are recorded at the set interval.
- A patient who does not meet the criteria stays, or is admitted.
- Stop and get help straight away if: a patient is discharged before the written discharge criteria are met.
1. Purpose
To keep patients safe in the hour after anaesthesia, when risk is highest (6.3).
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
Patients are most at risk in the hour after anaesthesia. Monitoring in recovery until written discharge criteria are met is what finds the complication before the patient leaves.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Recovery nurse | Monitors and records | Trained nurse |
| Anaesthetist | Decides discharge with the nurse | 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. Monitor.
- Record observations at the set interval (DAY-FRM-003) from arrival in recovery.
Key point: From arrival, not later.
Step 2. Assess discharge.
- Check each discharge criterion before the patient is moved from recovery.
Key point: Criteria are met, not hoped.
Step 3. Escalate.
- If a criterion is not met, keep the patient and tell the anaesthetist.
Key point: Not met, not discharged.
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 monitored to the set interval | At least 90% | Monthly | Lead nurse | Escalate to clinical director |
| Discharges with all criteria recorded as met | 100% | Monthly | Lead nurse | Escalate to 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 |
|---|---|---|
| DAY-FRM-003 | Recovery observation and discharge criteria record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the ASA Standards for Basic Anesthetic Monitoring (2020) for post-anaesthesia care. |
| 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
- Aftercare & Follow-up: Standards for Safe Discharge (H-06)
- Medical Emergency Protocol Development (MED-01)
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)