Standards › Standard 53 › Standard operating procedures (SOPs)
SOP · ALR-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 53.1
At a glance
- Every patient has an allergy history taken and recorded before any drug, product or allergen is given (ALR-FRM-001).
- The history records the agent, the reaction and its severity, and the date.
- The record is checked and updated at each new prescription and each change of condition.
- A patient with no known allergy is recorded as such, with the date checked.
- Stop and get help straight away if: a drug, product or allergen is given to a patient whose allergy history is not recorded.
1. Purpose
To make sure every patient’s allergies are known and recorded before anything that could trigger a reaction is given (53.1).
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
To make sure every patient’s allergies are known and recorded before anything that could trigger a reaction is given (53.1).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Treating clinician | Takes and records the allergy history | Clinical lead |
| Nurse | Checks the record before each administration | Treating clinician |
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. Ask.
- Ask about allergies to drugs, products, foods and other agents, and about past reactions.
Key point: Asked.
Step 2. Record.
- Record each allergy with the agent, the reaction, its severity and the date (ALR-FRM-001).
Key point: Recorded.
Step 3. Check.
- Check the record before each new drug or product is given, and update it at each change.
Key point: Checked.
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 allergy history recorded before first administration | 100% | Monthly | Clinical lead | Escalate to the hospital director |
| Records checked at each new prescription | 100% | Monthly | Clinical lead | Review the record before the next dose |
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 |
|---|---|---|
| ALR-FRM-001 | Allergy history record | Record |
| HOS-POL-001 | Medicines management policy (existing, reused) | Policy |
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
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)