Standards › Standard 48 › Standard operating procedures (SOPs)
SOP · PRS-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 48.3
At a glance
- Every pressure injury is staged with a recognised classification at first sight.
- Treatment follows the written protocol for the stage, and is recorded (PRS-REG-001).
- Injuries that develop during care are reviewed within 7 days (HOV-SOP-001).
- Staff who stage injuries are trained in the classification.
- Stop and get help straight away if: a pressure injury is untreated, unstaged, or not recorded.
1. Purpose
To make sure every pressure injury is staged, treated under a written protocol, and recorded (48.3).
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
A pressure injury must be classified, treated under a written plan and recorded. Without that, the next clinician cannot see how it is changing.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Ward nurse | Stages each injury and starts the treatment protocol | Ward manager |
| Tissue viability lead | Advises on complex injuries and keeps the protocol current | Clinical 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. Stage.
- Stage the injury with the recognised classification and record the stage.
Key point: Staged.
Step 2. Treat.
- Start the treatment for that stage under the written protocol.
Key point: Treated.
Step 3. Record.
- Record the injury, its stage, the treatment and whether it developed during care (PRS-REG-001).
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 |
|---|---|---|---|---|
| Injuries staged on first sight | 100% | Monthly | Ward manager | Escalate to the clinical lead |
| Injuries recorded in the register | 100% | Monthly | Ward manager | Record within 24 hours |
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 |
|---|---|---|
| PRS-REG-001 | Pressure injury register | Register |
| CLN-SOP-004 | Pressure injury risk assessment and prevention (existing, reused) | SOP |
17. Evidence
| Reference | Note |
|---|---|
| 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
- Slip, Trip & Fall Prevention (FALL-01)
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)