Standards › Standard 10 › Policies
Policy · HSP-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 10 (Hospice and Palliative Care), criterion 10.1
At a glance
- Pain and other symptoms (breathlessness, nausea, anxiety, agitation) are assessed on a fixed schedule with a validated tool (HSP-FRM-001).
- Each patient has a written symptom plan, reviewed when the condition changes.
- A symptom that is not controlled within a set time is reviewed the same day.
- Pain control follows the pain policy (MNP-POL-003).
- Stop and get help straight away if: a patient has uncontrolled pain or breathlessness with no review and no change to the plan.
1. Purpose
To assess and control the symptoms that cause most suffering in serious illness (10.1).
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
Pain and other symptoms such as breathlessness, nausea and agitation drive most of the suffering in serious illness. Assessing them on a schedule, and acting on the scores, is what keeps patients comfortable.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Lead palliative clinician | Owns the policy and the symptom plans | Clinician |
| Nurse | Assesses on schedule and records | 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. Assess.
- Assess pain and symptoms on the set schedule with HSP-FRM-001.
Key point: On schedule, with a tool.
Step 2. Plan.
- Write the symptom plan with the treatment and the review date, following MNP-SOP-002.
Key point: Written, with a review date.
Step 3. Review.
- Review each uncontrolled symptom the same day, and change the plan.
Key point: Same day.
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 with a symptom assessment on schedule | 95% | Monthly | Lead palliative clinician | Escalate to medical 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 |
|---|---|---|
| HSP-FRM-001 | Symptom assessment chart | Chart |
| MNP-POL-003 | Pain assessment and management (existing, reused) | Policy |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Palliative Care guidance and the WHO Package of Essential Noncommunicable Disease interventions (2020). |
| 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 |
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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)