Standards › Standard 41 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · TRM-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 41.2
At a glance
- Before treatment, each patient is told which parts of the practice are supported by evidence and which are not (TRM-FRM-001).
- No claim is made that the service cures or prevents a condition without evidence.
- The patient is given the statement in writing.
- Consent is taken after the statement is explained.
- Stop and get help straight away if: treatment starts with no evidence statement, or a claim is made with no evidence.
1. Purpose
To make sure patients make informed choices and are not misled about what treatment can do (41.2).
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
Patients have a right to know whether a traditional or complementary treatment has evidence behind it. Telling them honestly, before treatment, lets them decide with full information.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Service lead | Owns the statement and the claims rules | Clinical director |
| Practitioner | Gives the statement and records it | Service lead |
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 honestly which parts of the practice are supported by evidence and which are not.
Key point: Explained.
Step 2. Record.
- Record the statement given and the patient’s understanding (TRM-FRM-001).
Key point: Recorded.
Step 3. Consent.
- Take consent only after the statement is explained (CON-SOP-001).
Key point: Consented.
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 with an evidence statement before treatment | 100% | Quarterly | Service lead | 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 |
|---|---|---|
| TRM-FRM-001 | Evidence disclosure record | Record |
| CON-SOP-001 | Informed consent before significant care (existing) | Procedure |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Traditional Medicine Strategy 2014–2023, the WHO guidance on substandard and falsified medical products, and the ASF Hospital standard for informed consent and incident reporting. |
| 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)