Standards › Standard 9 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · FLD-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 9.10
At a glance
- Patients and staff are offered psychological support, and the offer is recorded.
- Staff are offered a debrief after each critical incident.
- Support is referred to a named person or service.
- Offers and answers are recorded on FLD-FRM-004.
- Stop and get help straight away if: a distressed patient or staff member is not offered support, or the offer is not recorded.
1. Purpose
To support patients and staff through trauma, loss and exhaustion (9.10).
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
People in a field setting face trauma, loss and exhaustion. Offering psychological support, and recording the offer, makes sure it reaches those who need it.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Psychosocial lead | Makes the offer and runs the debrief | Counsellor |
| Nurse | Records the offer and the answer | Nurse |
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. Offer support.
- Offer support to every patient with a traumatic event, and to staff after a critical incident.
Key point: Offered, not waited for.
Step 2. Record.
- Record the offer and the answer on FLD-FRM-004.
Key point: Always recorded.
Step 3. Refer.
- Refer to the named service the same day where the person accepts.
Key point: Same-day referral.
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 |
|---|---|---|---|---|
| Offers recorded | 100% | Monthly | Psychosocial lead | Escalate to field unit lead |
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 |
|---|---|---|
| FLD-FRM-004 | Psychosocial offer and debrief record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the IASC Guidelines for Mental Health and Psychosocial Support in Emergency Settings (2007). |
| 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.
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)