Standards › Standard 16 › Standard operating procedures (SOPs)
Procedure · PED-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 16.7
At a glance
- Check the schedule at each contact with a child.
- Book and record any missed check or dose.
- Contact the family within the set time for each missed item.
- Record the outcome on PED-REG-003.
- Stop and get help straight away if: a child is lost from the schedule with no contact made.
1. Purpose
To bring children back onto the schedule when a check or dose is missed (16.7).
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
Immunisation and child health checks catch illness early and prevent serious disease. Following a schedule, and recording each check, keeps children on track.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Nurse | Checks the schedule and contacts the family | Clinician |
| Clinical lead for primary care | Reviews missed items each month | 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. Check at each contact.
- Compare the child with the schedule at each visit.
Key point: Compared.
Step 2. Contact the family.
- Contact the family within the set time, and book the missed item.
Key point: Contacted and booked.
Step 3. Close the item.
- Record the outcome on PED-REG-003 and close the item when given.
Key point: Closed.
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 |
|---|---|---|---|---|
| Missed items followed up within the set time | 95% | Monthly | Clinical lead for primary care | 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 |
|---|---|---|
| PED-REG-003 | Child health schedule register | Register |
| PED-POL-003 | Child health checks and immunisation | Policy |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Pocket book of hospital care for children (2013) and the UN Convention on the Rights of the Child (1989). |
| 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.
Planned course: Immunisation and child health checks. New course planned.
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)