Standards › Standard 10 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · HSP-SOP-004 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 10 (Hospice and Palliative Care), criterion 10.10
At a glance
- Each patient has a named clinician with access to their plan, reachable at all hours.
- The number is given to the patient and family in writing.
- Each out-of-hours contact is recorded (HSP-REG-003) with the time and the advice given.
- A crisis is escalated at once to the on-call doctor.
- Stop and get help straight away if: a family calls out of hours and no clinician with the plan is reachable.
1. Purpose
To give a named, reachable clinician for symptom crises at any hour (10.10).
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
Symptoms at night can be frightening and dangerous. A named clinician, reachable at any hour and with the patient’s plan, gives the family a safe answer instead of a crisis.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Lead palliative clinician | Owns the on-call rota | Clinician |
| On-call clinician | Answers and records each contact | 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. Name the clinician.
- Name the on-call clinician for each patient on the plan, and give the number in writing.
Key point: A named person and number.
Step 2. Answer.
- Answer each call with access to the patient’s plan, and advise.
Key point: With the plan in hand.
Step 3. Record.
- Record each contact on HSP-REG-003 with the time and the advice given.
Key point: Every contact.
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 |
|---|---|---|---|---|
| Out-of-hours calls answered with a record | 100% | Monthly | Lead palliative clinician | Escalate to medical 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 |
|---|---|---|
| HSP-REG-003 | Out-of-hours contact log | Log |
17. 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. |
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)