Standards › Standard 38 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · SUB-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 38.1
At a glance
- Each person has a substance use assessment before a treatment plan is agreed (SUB-FRM-001).
- The assessment uses a named, validated screening or assessment tool.
- The score is recorded and the assessment is repeated at the set interval.
- No plan is agreed without the assessment on file.
- Stop and get help straight away if: a treatment plan is agreed with no assessment on file.
1. Purpose
To make sure treatment is based on a measured picture of each person’s substance use (38.1).
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
Substance use treatment starts with knowing what the person uses, how much and how often. A validated screening tool gives a common starting point that can be compared over time.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead for addiction services | Owns the tool choice and the assessment standard | Clinical director |
| Assessing clinician | Carries out the assessment and records it | Clinical lead for addiction services |
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.
- Use the named validated tool to assess the person’s substance use.
Key point: Assessed.
Step 2. Record.
- Record the tool, the score and the date (SUB-FRM-001).
Key point: Recorded.
Step 3. Repeat.
- Repeat the assessment at the set interval and record it.
Key point: Repeated.
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 |
|---|---|---|---|---|
| People with an assessment before their plan | 100% | Monthly | Clinical lead for addiction services | Escalate to the clinical 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 |
|---|---|---|
| SUB-FRM-001 | Substance use assessment record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO guidelines for the psychosocially assisted pharmacological treatment of opioid dependence (2009), the WHO Guidelines on HIV and harm reduction for people who inject drugs, and the ASF Ambulatory standard for addiction services. |
| 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
- Narcology & Addiction Treatment (AMB-21)
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)