Standards › Standard 8 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · FRT-SOP-005 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 8.8
At a glance
- Every patient is offered psychological support before, during and after treatment.
- The offer is recorded, and the answer is recorded.
- Support is offered again at each major stage and after a loss.
- A patient who accepts is referred the same week.
- Stop and get help straight away if: a patient who is distressed is not offered support, or the offer is not recorded.
1. Purpose
To support patients through the emotional strain of treatment (8.8).
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
Fertility treatment brings emotional strain. Offering psychological support during and after treatment, and recording the offer, makes support available when it is needed.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Counsellor | Makes the offer and provides support | Counsellor |
| Nurse | Records the offer and the answer | Nurse |
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. Offer.
- Offer psychological support at the start, at each major stage and after any loss (FRT-FRM-004).
Key point: Offered, not waited for.
Step 2. Record.
- Record the offer and whether the patient accepted or declined.
Key point: The offer is always recorded.
Step 3. Refer.
- Refer a patient who accepts the same week.
Key point: The same week.
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 |
|---|---|---|---|---|
| Patients offered support recorded | 100% | Monthly | Clinical director | Escalate to chief executive |
| Accepted referrals seen within a week | At least 90% | Monthly | Counsellor | Escalate to clinical director |
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 |
|---|---|---|
| FRT-FRM-004 | Psychological support offer record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on NICE guideline CG156 on fertility problems (2013, updated). |
| 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)