Standards › Standard 40 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · NUT-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 40.3
At a glance
- Each patient is screened for malnutrition with a named validated tool.
- Weight and intake are monitored against documented targets (LTC-REG-001).
- Treatment is started and reviewed when malnutrition is found.
- The screen and its score are recorded at admission and at the set interval.
- Stop and get help straight away if: a patient at risk of malnutrition has no screen and no monitoring.
1. Purpose
To find malnutrition early and treat it before it harms the patient (40.3).
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
Malnutrition slows recovery, weakens the immune system and can kill. Identifying it with a validated tool, and treating it, prevents harm.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Lead dietitian | Owns the screening tool and the monitoring standard | Clinical director |
| Nurse or clinician | Screens, weighs and records intake | Lead dietitian |
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. Screen.
- Screen each patient with the named validated tool at admission and record the score.
Key point: Screened.
Step 2. Monitor.
- Weigh and record intake against target at the set interval (LTC-REG-001).
Key point: Monitored.
Step 3. Treat.
- Start treatment for any positive screen and review it.
Key point: Treated.
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 |
|---|---|---|---|---|
| Patients screened at admission | 100% | Monthly | Lead dietitian | 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 |
|---|---|---|
| LTC-REG-001 | Falls, pressure injury and weight register (existing) | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the ESPEN guideline on clinical nutrition and hydration (2019), the WHO Five Keys to Safer Food (2006), and the ASF Hospital and Long-Term Care standards for nutrition care. |
| 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
- Personal Care & Daily Living (LTC-03)
Planned course: No e-learning course is linked to this criterion yet. A course is planned to cover it.
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)