Standards › Standard 31 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · DEN-SOP-006 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 31.16
At a glance
- Each patient is assessed for fitness and risk before surgery, including medicines that affect bleeding.
- Signed consent is obtained before the procedure (CON-FRM-001).
- Follow-up is arranged before the patient leaves and its outcome is recorded.
- A complication is recorded and reviewed.
- Stop and get help straight away if: surgery starts with no assessment, no signed consent or no check on anticoagulant medicines.
1. Purpose
To make sure minor oral surgery is assessed, consented and followed up (31.16).
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
Simple extractions are minor, but they can cause bleeding, infection or reactions. Assessing the patient, getting consent and following up keep them safe.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Operating clinician | Assesses, consents and carries out the procedure | Clinical director |
| Dental nurse or assistant | Records the follow-up appointment | Operating 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. Assess.
- Record the medical history, the medicines and the bleeding risk.
Key point: Assessed.
Step 2. Consent.
- Explain the risks and alternatives and obtain signed consent (CON-FRM-001).
Key point: Consented.
Step 3. Follow up.
- Arrange the follow-up and record the outcome.
Key point: Followed up.
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 |
|---|---|---|---|---|
| Surgeries with assessment, consent and follow-up recorded | 100% | Monthly | Clinical director | Escalate to the 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 |
|---|---|---|
| CON-FRM-001 | Consent record (existing, reused) | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the CDC guidelines for infection control in dental health-care settings (Kohn et al., 2003), ISO 17665 for moist-heat sterilisation, the Minamata Convention on Mercury (2013), IAEA Specific Safety Guide SSG-46 (2018), Council Directive 2013/59/Euratom, and the ADA guidelines on sedation (2016). |
| 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)