Standards › Standard 56 › Standard operating procedures (SOPs)
SOP · CAR-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 56.1
At a glance
- Every patient referred for a cardiac investigation or procedure has a documented cardiac risk assessment (CAR-FRM-001).
- The assessment covers symptoms, the resting ECG, cardiovascular risk factors and the planned procedure.
- The decision to proceed, or to defer, is recorded and signed by the cardiologist.
- Patients at high risk are reviewed by a senior cardiologist before the procedure.
- Stop and get help straight away if: a cardiac procedure goes ahead without a recorded risk assessment and decision.
1. Purpose
To make sure cardiac investigations and procedures are done only after a recorded risk assessment and decision (56.1).
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 cardiac investigations and procedures are done only after a recorded risk assessment and decision (56.1).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Cardiologist | Carries out and signs the risk assessment and the decision | Clinical lead |
| Cardiac nurse | Records the history, the ECG and the risk factors | Cardiologist |
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. Assess.
- Assess symptoms, the resting ECG, the risk factors and the planned procedure (CAR-FRM-001).
Key point: Assessed.
Step 2. Decide.
- Decide to proceed or defer, and record the reason.
Key point: Decided.
Step 3. Review high risk.
- Refer high-risk patients to a senior cardiologist before the procedure.
Key point: Reviewed.
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 |
|---|---|---|---|---|
| Procedures with a signed risk assessment before the date | 100% | Monthly | Clinical lead | Cancel the procedure |
| High-risk patients reviewed by a senior cardiologist | 100% | Monthly | Clinical lead | Escalate to the hospital 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 |
|---|---|---|
| CAR-FRM-001 | Cardiac risk assessment record | Record |
| FW-PLN-001 | Cardiac and medical emergency plan (existing, reused) | Plan |
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
- Cardiology & Cardiac Catheterization (AMB-14)
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)