Standards › Standard 32 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · AES-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 32.2
At a glance
- Consent states realistic outcomes, including that results vary and may not be permanent (AES-FRM-001).
- Risks, complications and alternatives are explained and recorded (CON-SOP-001).
- The patient is given a set period to reconsider before the procedure.
- No procedure is done on the day of the first consultation.
- Stop and get help straight away if: a procedure is performed on the day of the first consultation, or the patient has not been told the realistic outcome.
1. Purpose
To make sure each patient understands realistic outcomes and has time to reconsider before treatment (32.2).
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
For elective procedures there is time to decide. The patient should receive realistic information about the outcome, and time to reconsider before committing.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Practitioner | Explains the outcomes and obtains consent | Clinical director |
| Clinical director | Sets the reconsideration period | 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. Explain.
- Explain the realistic outcome, the risks, complications and alternatives.
Key point: Explained.
Step 2. Consent and reconsider.
- Record the consent and the reconsideration date (AES-FRM-001).
- Give the patient the set period to reconsider.
Key point: Reconsidered.
Step 3. Confirm before treatment.
- Confirm the patient still wishes to proceed on the day of treatment.
Key point: Confirmed.
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 |
|---|---|---|---|---|
| Consents with realistic outcomes and reconsideration 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 |
|---|---|---|
| AES-FRM-001 | Aesthetic procedure consent and reconsideration record | Record |
| CON-SOP-001 | Informed consent before significant care (existing, reused) | Procedure |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO guidance on patient rights and informed consent, the WHO Global Patient Safety Action Plan 2021–2030, the American Dental Association guidelines on sedation and general anaesthesia (2016) for the sedation principles adapted to aesthetic practice, and the American Heart Association guidelines for cardiopulmonary resuscitation (2020). |
| 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)