Standards › Standard 54 › Standard operating procedures (SOPs)
SOP · DRM-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 54.1
At a glance
- Every skin lesion is examined with a documented method, and its features are recorded (DRM-FRM-001).
- A lesion with features suspicious for malignancy is referred urgently, within the time set in this procedure.
- The referral and its date are recorded, and the patient is told the result of the referral.
- Lesions that are biopsied are tracked to a recorded pathology result.
- Stop and get help straight away if: a lesion with features suspicious for malignancy is not referred, or its referral is not recorded.
1. Purpose
To make sure skin lesions are examined by a set method, and that suspicious lesions reach specialist care in time (54.1).
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 skin lesions are examined by a set method, and that suspicious lesions reach specialist care in time (54.1).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Dermatologist | Examines suspicious lesions and makes the referral decision | Clinical lead |
| Clinician | Records the examination and refers at once when a feature is suspicious | Dermatologist |
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. Examine.
- Examine the lesion and record its size, colour, border and any change (DRM-FRM-001).
Key point: Examined.
Step 2. Refer.
- Refer any suspicious lesion urgently and record the date of referral.
Key point: Referred.
Step 3. Track.
- Track each biopsy to a recorded pathology result and tell the patient.
Key point: Tracked.
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 |
|---|---|---|---|---|
| Suspicious lesions referred within the set time | 100% | Monthly | Clinical lead | Escalate to the hospital director |
| Biopsies with a recorded pathology result | 100% | Monthly | Clinical lead | Chase the result within 5 working days |
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 |
|---|---|---|
| DRM-FRM-001 | Skin lesion examination and referral record | Record |
| AFT-FRM-001 | Follow-up booking before discharge (existing, reused) | Record |
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)