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Form · HSP-FRM-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 10 (Hospice and Palliative Care), criterion 10.1
Purpose
Records the validated score for each symptom at each assessment, and the change to the plan.
How to complete
- Use the same validated tool each time.
- Record the score and the time.
- Record any change to the plan.
Checks
| Check | Entry |
|---|---|
| Validated tool used (name) | Yes |
| Pain score and time | Yes |
| Breathlessness, nausea, anxiety, agitation scores | Yes |
| Plan changed (yes or no) and reason | Yes |
| Next review date | Yes |
| Recorded by and date | Yes |
Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Palliative Care guidance and the WHO Package of Essential Noncommunicable Disease interventions (2020). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
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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)