Standards › Standard 7 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · EDP-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 7.2
At a glance
- Each call is triaged with the recognised protocol.
- The priority decides the response.
- The triage decision and the response are recorded.
- A call that the protocol does not cover goes to the clinical advice line.
- Stop and get help straight away if: a call is sent with no triage decision, or a high-priority call gets a low-priority response.
1. Purpose
To sort each call by how urgent it is, and to match the response to it (7.2).
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
Each call must be sorted by how urgent it is, using a recognised protocol. Without it, the caller who sounds calm can wait behind the one who is dying.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Call taker | Triages each call with the protocol | Trained call taker |
| Shift supervisor | Checks the triage on sample calls | Supervisor |
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. Triage.
- Follow the recognised protocol question by question, and set the priority (EDP-FRM-001).
Key point: The protocol, not memory.
Step 2. Match.
- Send the response for that priority, using the emergency triage standard (HOS-SOP-001) for clinical priority.
Key point: Priority decides the response.
Step 3. Record.
- Record the triage decision and the response on the call record.
Key point: Recorded, every call.
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 |
|---|---|---|---|---|
| Calls triaged with a protocol recorded | 100% | Monthly | Operations manager | Escalate to chief executive |
| High-priority calls with a matching response | At least 90% | Monthly | Operations manager | 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 |
|---|---|---|
| EDP-FRM-001 | Call triage and response record | Record |
| HOS-SOP-001 | Emergency triage | Clinical priority |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the International Academies of Emergency Dispatch Medical Priority Dispatch System protocols. |
| 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)