Standards › Standard 17 › Standard operating procedures (SOPs)
Procedure · PHA-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 17.2
At a glance
- Counsel the patient on each new medicine: how to take it, what to expect and what to report.
- Check understanding by asking the patient to explain it back.
- Record counselling for every high-risk medicine (PHA-FRM-001).
- Give the leaflet as well as the counselling, never instead of it.
- Stop and get help straight away if: a new medicine is dispensed with no counselling.
1. Purpose
To make sure each patient understands how to take a new medicine, and what to report (17.2).
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 patient who gets a new medicine without understanding how to take it may take it wrongly, or stop it. Counselling on new medicines, given and checked, is what makes the treatment work.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Dispensing pharmacist | Counsels the patient and records it | Pharmacist |
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. Counsel.
- Explain how to take the medicine, what to expect and what to report.
Key point: Explained.
Step 2. Check.
- Ask the patient to explain the dose and the warning signs back.
Key point: Understood.
Step 3. Record.
- Record the counselling on PHA-FRM-001 for high-risk medicines.
Key point: Recorded.
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 |
|---|---|---|---|---|
| New medicines counselled | 100% | Monthly | Responsible pharmacist | 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 |
|---|---|---|
| PHA-FRM-001 | Counselling record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Medication Without Harm guidance (2017) and the WHO Good storage and distribution practices (2010). |
| 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
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)