Standards › Standard 54 › Standard operating procedures (SOPs)
SOP · DRM-SOP-004 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 54.5
At a glance
- Each patient who has a procedure receives a written aftercare sheet at discharge (DRM-FRM-003).
- Each patient whose lesion is sent for pathology is told when and how they will get the result.
- Follow-up for the result is booked before the patient leaves (AFT-FRM-001).
- Patients who do not attend follow-up are contacted.
- Stop and get help straight away if: a patient leaves after a procedure without written aftercare, or a pathology result is not followed up.
1. Purpose
To make sure patients leave with written aftercare and a booked follow-up for their results (54.5).
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 patients leave with written aftercare and a booked follow-up for their results (54.5).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Dermatologist | Makes sure the aftercare is written and the follow-up booked | Clinical lead |
| Nurse | Gives the aftercare sheet and books the follow-up | 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. Write.
- Write the aftercare sheet for the procedure and give it to the patient.
Key point: Written.
Step 2. Book.
- Book the pathology follow-up before the patient leaves (AFT-FRM-001).
Key point: Booked.
Step 3. Follow up.
- Contact any patient who does not attend, and record the result given (DRM-FRM-003).
Key point: Followed.
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 written aftercare given | 100% | Monthly | Clinical lead | Escalate to the clinical lead |
| Pathology follow-up booked before discharge | 100% | Monthly | Clinical lead | Book before the next visit |
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-003 | Aftercare and pathology follow-up 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)