Standards › Standard 53 › Standard operating procedures (SOPs)
SOP · ALR-SOP-004 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 53.5
At a glance
- Each allergy result and its advice is communicated to the patient and the referrer (ALR-FRM-004).
- Each patient receives a written action plan for avoidance and for emergency treatment.
- The allergy alert on the record is updated when a result changes the allergy history.
- Results with urgent findings are reported as critical results (HOS-SOP-009).
- Stop and get help straight away if: a result that changes the allergy history is not added to the record.
1. Purpose
To make sure allergy results are communicated and acted on, with a written action plan for each patient (53.5).
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 allergy results are communicated and acted on, with a written action plan for each patient (53.5).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Allergologist | Communicates the result and signs the action plan | Clinical lead |
| Referring clinician | Acts on the action plan and updates the record | Allergologist |
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. Communicate.
- Tell the patient and the referrer the result and the advice, and record that it was done.
Key point: Communicated.
Step 2. Plan.
- Give the patient a written action plan (ALR-FRM-004).
Key point: Planned.
Step 3. Update.
- Update the allergy alert on the record when the result changes the allergy history.
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 |
|---|---|---|---|---|
| Results with the advice communicated and recorded | 100% | Monthly | Allergologist | Escalate to the clinical lead |
| Allergy alerts updated after a changed result | 100% | Monthly | Allergologist | Update the record at once |
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-004 | Allergy action plan | Record |
| LBT-SOP-008 | Laboratory report content and delivery (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)