Standards › Standard 15 › Policies
Policy · OPT-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 15 (Optical and Hearing), criterion 15.1
At a glance
- Each test uses a validated method, named on OPT-FRM-001.
- Test equipment is maintained and calibrated on the schedule in EQP-SOP-001.
- Each result is recorded, and any finding that needs referral is referred (OPT-POL-003).
- A test with unvalidated method or faulty equipment is not used.
- Stop and get help straight away if: a test is given with an unvalidated method or equipment past its calibration date.
1. Purpose
To make sure each sight and hearing test is clinically sound (15.1).
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
A sight or hearing test that uses an unvalidated method or poor equipment gives the wrong answer, and the patient is fitted with the wrong product. The test is the start of every correct fitting.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Lead optometrist or audiologist | Owns the test methods and equipment rule | Clinician |
| Tester | Runs each test and records the result | 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. Use a validated method.
- Name the validated method on OPT-FRM-001 for each test.
Key point: Validated, named.
Step 2. Check the equipment.
- Check the calibration date before each test (EQP-REG-001).
Key point: In calibration.
Step 3. Record and refer.
- Record each result and refer any finding that needs it.
Key point: Recorded, referred.
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 |
|---|---|---|---|---|
| Tests with validated method and in-calibration equipment | 100% | Monthly | Lead optometrist or audiologist | 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 |
|---|---|---|
| OPT-FRM-001 | Sight and hearing test record | Record |
| EQP-SOP-001 | Medical equipment maintenance and removal from use (existing, reused) | Procedure |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO World report on vision (2019) and the WHO World report on hearing (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)