Standards › Standard 7 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · EDP-SOP-005 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 7.9
At a glance
- A clinician is available to call takers at all hours.
- Call takers use the clinician for cases the protocol does not cover, and for every escalation.
- Each piece of advice is recorded with its outcome.
- The clinician checks the advice is followed up.
- Stop and get help straight away if: a case outside the protocol is handled with no clinician involved, or advice is given with no record.
1. Purpose
To give call takers a clinician when the protocol is not enough (7.9).
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
Call takers face cases the protocol does not cover. A clinician who can be reached at any hour gives them support before a decision is made alone.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead | Runs the clinician rota | Clinician |
| Clinician on duty | Gives advice and records it | Clinician |
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. Call.
- The call taker contacts the clinician on duty for any case outside the protocol or any escalation.
Key point: No case without a clinician.
Step 2. Advise.
- The clinician gives advice and records it on EDP-FRM-003.
Key point: The advice is recorded.
Step 3. Follow up.
- Record the outcome of the advice on the call record.
Key point: The outcome is known.
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 |
|---|---|---|---|---|
| Advice requests answered by a clinician | 100% | Monthly | Clinical lead | Escalate to chief executive |
| Advice with outcome recorded | 100% | Monthly | Clinical lead | Escalate to chief executive |
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 |
|---|---|---|
| EDP-FRM-003 | Clinical advice and escalation record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | ASF Expert Committee consensus. |
| 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)