Standards › Standard 12 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · GYN-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 12 (Obstetrics and Gynaecology), criterion 12.13
At a glance
- Women are offered cervical and breast screening on the national schedule.
- Each result is followed up, and an abnormal result is referred within the set time.
- Women who do not attend are recalled (PHC-REG-003).
- Each offer, result and referral is recorded (GYN-REG-001).
- Stop and get help straight away if: an abnormal screening result is not referred within the set time.
1. Purpose
To find cervical and breast cancer early through screening that is followed up (12.13).
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
Cervical and breast cancers are found earlier when screening is offered on schedule and results are acted on. A screening result that is not followed up can cost a life.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Lead gynaecologist or obstetrician | Owns the screening rule | Clinician |
| Screening coordinator | Runs the recall and records results | 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.
- Offer screening on the national schedule and record each offer.
Key point: On schedule.
Step 2. Follow up.
- Follow up each result, and recall women who do not attend (PHC-SOP-006).
Key point: Every result.
Step 3. Refer.
- Refer each abnormal result within the set time and record the referral.
Key point: Within the set time.
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 |
|---|---|---|---|---|
| Abnormal results referred within the set time | 100% | Quarterly | Lead gynaecologist or obstetrician | 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 |
|---|---|---|
| GYN-REG-001 | Screening recall and result register | Register |
| PHC-SOP-006 | Screening offer and follow-up (existing, reused) | Procedure |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO guidelines for screening and treatment of precancerous lesions for cervical cancer prevention (2021). |
| 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 |
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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)