Standards › Standard 58 › Standard operating procedures (SOPs)
SOP · WRD-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 58.1
At a glance
- Each inpatient has falls, pressure, nutrition and VTE risk assessments within 24 hours of admission (PSF-FRM-002, CLN-FRM-006, CLN-FRM-005, CLN-FRM-007).
- A clinician reviews the plan every day and records it (WRD-FRM-001).
- A change in risk is reflected in the plan on the same day.
- Stop and get help straight away if: an inpatient has no admission assessment, or a day passes with no clinician review.
1. Purpose
To make sure every inpatient is assessed on admission and reviewed daily (58.1).
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 inpatient is assessed on admission and reviewed daily (58.1).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Ward doctor | Carries out the daily review and signs the plan | Clinical lead |
| Ward nurse | Completes the risk assessments on admission | Ward doctor |
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.
- Complete the four risk assessments within 24 hours of admission.
Key point: Assessed.
Step 2. Review.
- Review the plan every day and record it (WRD-FRM-001).
Key point: Reviewed.
Step 3. Update.
- Update the plan the same day if a risk changes.
Key point: Updated.
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 |
|---|---|---|---|---|
| Inpatients with all four assessments within 24 hours | 100% | Monthly | Clinical lead | Complete the assessment at once |
| Inpatient days with a daily review recorded | 100% | Monthly | Clinical lead | Escalate to the ward lead |
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 |
|---|---|---|
| WRD-FRM-001 | Ward admission and daily review record | Record |
| PSF-SOP-001 | Falls 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
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)