Standards › ASF Health Standards v10 › Standard 54
Standard 54
Dermatology and Skin Clinics
Dermatology and skin clinics: skin lesions examined and suspicious lesions referred, minor procedures done with sterile technique, laser and light devices operated safely, systemic drugs monitored, and patients leave with written aftercare and a booked follow-up..
Each criterion is shown in three settings: Humanitarian settings, Transition and fragile, and Standard. In standard settings, every criterion is Must.
Training colours: red means essential, green recommended, yellow optional. Each course shows its level for each setting: humanitarian, transition and fragile, and standard.
54.1Skin Lesions Are Examined and Suspicious Lesions ReferredHumanitarian settings: MinimumTransition and fragile: MustStandard: Must
Every skin lesion is examined by a documented method. A lesion with features suspicious for malignancy is referred urgently, and each biopsy is tracked to a recorded pathology result.
Why it matters.
How the surveyor verifies this criterion
Sample. Review skin lesion records and referrals for a sample of patients in the last 6 months, including every biopsy taken.
1. Every skin lesion is examined by a documented method.
Method. Check each sampled record for the examination features recorded.
Evidence to show. Skin lesion examination and referral record (DRM-FRM-001).
Pass when. Every sampled lesion has its features recorded.
2. A lesion suspicious for malignancy is referred urgently.
Method. Check each sampled suspicious lesion for the referral date against the time set.
Evidence to show. Skin lesion examination and referral record (DRM-FRM-001).
Pass when. Every sampled suspicious lesion was referred within the set time.
3. Each biopsy is tracked to a pathology result.
Method. Check each sampled biopsy for the pathology result and the date the patient was told.
Evidence to show. Aftercare and pathology follow-up record (DRM-FRM-003).
Pass when. Every sampled biopsy has a recorded result and the patient was told it.
Immediate fail (any one means the criterion is not met). A changing pigmented lesion is recorded as benign and not referred, and is later found to be melanoma.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Nurse (ISCO 2221) | Completes the Skin lesion examination and urgent referral (DRM-SOP-001); skin lesion examination and referral record | Must |
| Manager (ISCO 1342) | Checks the criterion at each review | Must |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| DRM-SOP-001 · Skin lesion examination and urgent referral | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
| DRM-FRM-001 · Skin lesion examination and referral record | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Dermatology Safety & Accreditation Standards (AMB-17) | Manager; Nurse |
References
- WHO (2026). Integrated approach to management of skin-related neglected tropical diseases and common skin conditions. Used for: Skin lesion assessment and referral https://news.gmj.ge/guideline/integrated-approach-to-management-of-skin-related-neglected-tropical-diseases-and-common-skin-conditions/
- WHO (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Used for: Referral and follow-up of skin lesions https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/
54.2Skin Procedures Are Done With Sterile TechniqueHumanitarian settings: MustTransition and fragile: MustStandard: Must
Biopsies, excisions and other minor skin procedures are carried out with sterile technique, with hand hygiene, sterilised or single-use instruments, and safe sharps disposal.
Why it matters.
How the surveyor verifies this criterion
Sample. Observe minor skin procedures on several days and audit the records for the sample period.
1. Minor skin procedures are carried out with sterile technique.
Method. Observe a sample of procedures and check each against the technique steps.
Evidence to show. Sterile technique for minor skin procedures (DRM-SOP-002).
Pass when. Every observed procedure follows sterile technique.
Immediate fail (any one means the criterion is not met). A biopsy instrument is reused without sterilisation, and the patient develops a wound infection.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Manager (ISCO 1342) | Maintains the Sterile technique for minor skin procedures (DRM-SOP-002); sterile technique audit record | Must |
| Manager (ISCO 1342) | Checks the criterion at each review | Must |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| DRM-SOP-002 · Sterile technique for minor skin procedures | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Dermatology Safety & Accreditation Standards (AMB-17) | Manager; Nurse |
References
- WHO (2018). Global guidelines for the prevention of surgical site infection, second edition. Used for: Sterile technique and infection prevention https://news.gmj.ge/guideline/global-guidelines-for-the-prevention-of-surgical-site-infection-second-edition/
54.3Laser and Light Devices Are Operated SafelyHumanitarian settings: MustTransition and fragile: MustStandard: Must
Laser and light devices are operated only by staff signed off for each device. Skin type, device settings and contraindications are checked before each treatment, and eye protection is used during treatment.
Why it matters.
How the surveyor verifies this criterion
Sample. Review the device log and operator sign-off records for all laser and light devices in the last 12 months.
1. Each device is operated only by staff signed off for it.
Method. Compare each logged use with the operator sign-off list.
Evidence to show. Laser and light device use log (DRM-REG-002).
Pass when. Every logged use was by a signed-off operator.
2. Skin type, settings and contraindications are checked before each treatment.
Method. Check each logged treatment for the check entries.
Evidence to show. Laser and light device use log (DRM-REG-002).
Pass when. Every logged treatment has the checks recorded.
3. Eye protection is used during treatment.
Method. Check each logged treatment for the eye protection entry.
Evidence to show. Laser and light device use log (DRM-REG-002).
Pass when. Every logged treatment records eye protection.
Immediate fail (any one means the criterion is not met). A laser is used on the face without eye protection, and a patient suffers an eye injury.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Secretary (ISCO 3344) | Keeps the Laser and light device safety (DRM-POL-001); device use log | Must |
| Manager (ISCO 1342) | Checks the criterion at each review | Must |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| DRM-REG-002 · Laser and light device use log | Secretary (ISCO 3344) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
| DRM-POL-001 · Laser and light device safety | Chief executive (ISCO 1120) | Governing body members | N/A | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Dermatology Safety & Accreditation Standards (AMB-17) | Manager; Nurse |
References
- Joint Council for Cosmetic Practitioners (n.d.). JCCP Competency Framework for Cosmetic Practice, Version 8. Used for: Competence to operate laser and light devices https://news.gmj.ge/guideline/jccp-competency-framework-for-cosmetic-practice-version-8/
54.4Systemic Dermatology Drugs Are MonitoredHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must
Systemic drugs with monitoring needs are prescribed under a written protocol. Pregnancy prevention and the required tests are set before the first dose, and results are reviewed at the set interval.
Why it matters.
How the surveyor verifies this criterion
Sample. Review the records of patients on systemic dermatology drugs with monitoring needs in the last 12 months.
1. Systemic drugs with monitoring needs are prescribed under the written protocol.
Method. Check each sampled prescription against the protocol.
Evidence to show. Systemic dermatology drug monitoring (DRM-SOP-003).
Pass when. Every sampled prescription follows the protocol.
2. Pregnancy prevention and the required tests are set before the first dose.
Method. Check each sampled patient for the baseline tests and the pregnancy prevention plan before the first dose.
Evidence to show. Systemic drug monitoring and pregnancy prevention record (DRM-FRM-002).
Pass when. Every sampled patient has both recorded before the first dose.
3. Results are repeated at the interval and acted on.
Method. Check the monitoring dates against the interval and the action taken for each out-of-limit result.
Evidence to show. Systemic drug monitoring and pregnancy prevention record (DRM-FRM-002).
Pass when. Every test was repeated on time, and each out-of-limit result has a recorded action.
Immediate fail (any one means the criterion is not met). A patient on a systemic drug has no blood test for a year, and an abnormal result is missed.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Manager (ISCO 1342) | Maintains the Systemic dermatology drug monitoring (DRM-SOP-003); medicines management policy | Medium |
| Nurse (ISCO 2221) | Completes the Systemic drug monitoring and pregnancy prevention record | Medium |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| DRM-SOP-003 · Systemic dermatology drug monitoring | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
| DRM-FRM-002 · Systemic drug monitoring and pregnancy prevention record | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Dermatology Safety & Accreditation Standards (AMB-17) | Manager; Nurse |
References
- WHO (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Used for: Systemic medicines monitoring https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/
54.5Patients Leave With Written Aftercare and a Booked Follow-UpHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must
Each patient who has a procedure receives written aftercare at discharge. Patients awaiting a pathology result have a follow-up booked before they leave, and those who do not attend are contacted.
Why it matters.
How the surveyor verifies this criterion
Sample. Review discharge records for a sample of procedures and biopsies in the last 6 months.
1. Each patient who has a procedure receives written aftercare at discharge.
Method. Check each sampled procedure record for the aftercare sheet given.
Evidence to show. Aftercare and pathology follow-up record (DRM-FRM-003).
Pass when. Every sampled procedure has written aftercare recorded as given.
2. Patients who do not attend are contacted.
Method. Check each sampled non-attendance for the contact record.
Evidence to show. Aftercare and pathology follow-up record (DRM-FRM-003).
Pass when. Every sampled non-attendance has a recorded contact.
Immediate fail (any one means the criterion is not met). A patient with a biopsy leaves with no appointment, and the malignant result is never delivered.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Nurse (ISCO 2221) | Completes the Written aftercare and pathology follow-up (DRM-SOP-004); aftercare and pathology follow-up record | Medium |
| Manager (ISCO 1342) | Checks the criterion at each review | Medium |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| DRM-SOP-004 · Written aftercare and pathology follow-up | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
| DRM-FRM-003 · Aftercare and pathology follow-up record | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Dermatology Safety & Accreditation Standards (AMB-17) | Manager; Nurse |
References
In process of development. Will be available soon.
Who is responsible for Standard 54
Each criterion names the positions responsible for it. Every position links to its own terms of reference.
| Criterion | Responsible | Supports |
|---|---|---|
| 54.1 Skin Lesions Are Examined and Suspicious Lesions Referred | Dermatologist General practitioner (GP) |
Family physician (GP) lead |
| 54.2 Skin Procedures Are Done With Sterile Technique | Dermatologist Operating theatre nurse |
Infection prevention and control (IPC) lead |
| 54.3 Laser and Light Devices Are Operated Safely | Laser and device technician Dermatologist |
Dermatologist (aesthetic lead) |
| 54.4 Systemic Dermatology Drugs Are Monitored | Dermatologist Pharmacist (dispensing) |
Clinical pharmacist |
| 54.5 Patients Leave With Written Aftercare and a Booked Follow-Up | Dermatologist Practice nurse (immunisation, chronic care) |
Patient flow coordinator (clinic) |
Role details: reporting, supervision and training
Training shown is the general recommendation. Role-specific training is set in the next improvement round.
| Role | Reports to | Supervises | Recommended training |
|---|---|---|---|
| Infection prevention and control (IPC) lead | Quality manager | IPC nurse | Facility induction; safeguarding adults (general recommendation) |
| General practitioner (GP) | Medical director | None | Facility induction; safeguarding adults (general recommendation) |
| Dermatologist | Head of department (per specialty) | None | Facility induction; safeguarding adults (general recommendation) |
| Operating theatre nurse | Theatre manager | None | Facility induction; safeguarding adults (general recommendation) |
| Clinical pharmacist | Chief pharmacist | None | Facility induction; safeguarding adults (general recommendation) |
| Pharmacist (dispensing) | Chief pharmacist | None | Facility induction; safeguarding adults (general recommendation) |
| Practice nurse (immunisation, chronic care) | Family physician (GP) lead | None | Facility induction; safeguarding adults (general recommendation) |
| Family physician (GP) lead | Medical director | Practice nurse (immunisation, chronic care), Walk-in clinic physician, Same-day procedure nurse | Facility induction; safeguarding adults (general recommendation) |
| Patient flow coordinator (clinic) | Practice manager | None | Facility induction; safeguarding adults (general recommendation) |
| Dermatologist (aesthetic lead) | Aesthetic clinic medical director | Aesthetic physician (injectables) | Facility induction; safeguarding adults (general recommendation) |
| Laser and device technician | Dermatologist (aesthetic lead) | None | Facility induction; safeguarding adults (general recommendation) |
Questions and answers
The criterion text is the authority. These answers summarise it.
Who does Standard 61 apply to?
Dermatology clinics and skin services that examine lesions, carry out minor skin procedures, and operate laser or light devices.
What do the colours mean for this standard?
Red (Must) is required. Green (Medium) is recommended. Yellow (Minimum) is the lowest acceptable level in humanitarian settings. Standard setting is Must on every criterion.
Is every skin lesion examined in a set way?
Yes. Under 54.1 every lesion is examined by a documented method, a lesion suspicious for malignancy is referred urgently, and each biopsy is tracked to a recorded result.
Are minor skin procedures done under sterile conditions?
Yes. Under 54.2 biopsies and excisions use sterile technique, hand hygiene, sterilised or single-use instruments and safe sharps disposal.
Who may operate laser and light devices?
Under 54.3 only staff signed off for each device operate it, and skin type, settings and contraindications are checked before every treatment.
Are systemic dermatology drugs monitored?
Under 54.4 they are prescribed under a written protocol, with pregnancy prevention and required tests set before the first dose.
What do patients take home?
Under 54.5 each patient who has a procedure gets written aftercare, and anyone awaiting a pathology result has a follow-up booked before leaving.
Guidelines for this standard
22 guideline(s) are held in the GMJ Guidelines Library and listed here. Each link opens the full guideline on news.gmj.ge. The complete library, grouped by standard, is at Guidelines.
- Pressure ulcers: prevention and management (National Institute for Health and Care Excellence (UK))
- JCCP Competency Framework for Cosmetic Practice, Version 8 (Joint Council for Cosmetic Practitioners (UK))
- Guidance for doctors who offer cosmetic interventions (General Medical Council (UK))
- CMAC Guideline: Management of Hyaluronic Acid Filler-Induced Vascular Occlusion (Complications in Medical Aesthetics Collaborative)
- Necrotising infections of the skin and soft tissues — MSF Clinical guidelines (Médecins Sans Frontières)
- Leg ulcers — MSF Clinical guidelines (Médecins Sans Frontières)
- Cutaneous abscess — Clinical guidelines — Diagnosis and treatment manual — MSF Clinical guidelines (Médecins Sans Frontières)
- Venereal warts — MSF Clinical guidelines (Médecins Sans Frontières)
- Guidelines for the Clinical Diagnosis and Treatment of Dengue, Chikungunya, and Zika (Pan American Health Organization)
- Microplanning manual to guide implementation of preventive chemotherapy to control and eliminate neglected tropical diseases (Pan American Health Organization)
- National Onchocerciasis Elimination Committees: A Handbook for Expert Advisory Groups in Africa (World Health Organization)
- Essential care package to address mental health and stigma for persons with neglected tropical diseases (World Health Organization)
- Integrated approach to management of skin-related neglected tropical diseases and common skin conditions (World Health Organization)
- Operational guidelines for the elimination of human fascioliasis as a public health problem in the Americas (Pan American Health Organization)
- Routine health information system and health facility data for neglected tropical diseases: general guidance for national programme managers and data clerks (World Health Organization)
- Routine health information system and health facility and community data for neglected tropical diseases: last-mile logistics information system for medicines and health products (World Health Organization)
- Routine health information system and health facility data for neglected tropical diseases: Buruli ulcer (World Health Organization)
- Routine health information system and health facility data for neglected tropical diseases: Schistosomiasis (World Health Organization)
- Routine health information system and health facility data for neglected tropical diseases: Rabies (World Health Organization)
- Validation of elimination of soil-transmitted helminthiases as a public health problem in children: criteria and procedure (World Health Organization)
- Guidelines on leishmaniases: treatment of visceral leishmaniasis and post-kala-azar dermal leishmaniasis in eastern Africa and South-East Asia (World Health Organization)
- Routine health information system and health facility data for neglected tropical diseases: Taenia solium taeniasis and cysticercosis (World Health Organization)
Also relevant to this standard:
- Emergency treatment of anaphylaxis: guidelines for healthcare providers (Resuscitation Council UK)