Standards › Standard 31 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · DEN-SOP-008 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 31.23
At a glance
- Care is planned for the age, weight, communication and support needs of the patient.
- A carer or support is recorded and involved where needed.
- Staff who see these patients are trained for them.
- Any adaptation of care is recorded.
- Stop and get help straight away if: a child or a person with special needs is treated with no planning, no adaptation and no carer where one is needed.
1. Purpose
To make sure children and people with special needs receive safe, planned dental care (31.23).
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
Children, and people with a disability or other needs, may need more time, a different approach or a different setting. Care provided by staff trained for them is safer and more humane.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinician | Plans and gives the care | Clinical director |
| Clinical director | Owns the adaptations and the staff training | Medical 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. Plan.
- Plan the visit for the age, weight, communication and support needs.
Key point: Planned.
Step 2. Involve the carer.
- Record the carer or support and agree the plan with them.
Key point: Agreed.
Step 3. Give and record.
- Give the care with the agreed adaptations and record them.
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 |
|---|---|---|---|---|
| Visits with the plan and carer 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 |
|---|---|---|
| WRK-SOP-001 | Annual competency assessment procedure (existing, reused) | Procedure |
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
- Pediatric Ambulatory Care (AMB-23)
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)