Standards › Standard 31 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · DEN-SOP-007 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 31.21
At a glance
- Each laboratory order states the specification and the material (DEN-FRM-008).
- Items are disinfected before fitting and the step is recorded.
- Only approved laboratories are used, and their records are kept.
- The clinic can trace each item to its laboratory and to the patient.
- Stop and get help straight away if: an item is fitted without disinfection, or from a laboratory not on the approved list.
1. Purpose
To make sure laboratory work is correctly specified, disinfected and traceable to an approved laboratory (31.21).
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
Dental laboratories make crowns, dentures and other work that goes in the patient’s mouth. The clinic must specify the work on a written prescription, use a quality-assured lab, and disinfect the work on return.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical director | Approves the laboratories | Medical director |
| Clinician | Writes the order and checks the item before fitting | Clinical director |
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. Order.
- Write the specification and material on the order (DEN-FRM-008).
Key point: Ordered.
Step 2. Receive and disinfect.
- Disinfect the item on receipt and before fitting, and record it.
Key point: Disinfected.
Step 3. Fit and trace.
- Fit the item and keep the link to the laboratory and the patient.
Key point: Fitted.
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 |
|---|---|---|---|---|
| Items fitted with disinfection recorded | 100% | Quarterly | 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 |
|---|---|---|
| DEN-FRM-008 | Laboratory work order | 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)