Standards › Standard 33 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · LBT-SOP-008 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 33.13
At a glance
- Each report has the minimum content: identifiers, test, result, units, reference interval and authoriser.
- The report reaches the requester named on the request.
- Delivery is checked against the requester before release.
- A report sent to the wrong recipient is recalled and reported.
- Stop and get help straight away if: a report is sent to a recipient other than the requester, or without its identifiers.
1. Purpose
To make sure each report is complete and reaches the right person (33.13).
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
A report without the patient’s identity, the specimen type or the test date cannot be used safely. Every report must carry a defined minimum of information.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Senior scientist | Sets the minimum content and the delivery route | Laboratory director |
| Reporting staff | Check each report before it is sent | Senior scientist |
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. Check content.
- Check each report against the minimum content list.
Key point: Checked.
Step 2. Check recipient.
- Check the recipient against the requester on the request.
Key point: Recipient checked.
Step 3. Deliver.
- Send the report by the defined route and record the delivery.
Key point: Delivered.
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 |
|---|---|---|---|---|
| Reports with complete minimum content and correct recipient | 100% | Monthly | Senior scientist | Escalate to the laboratory 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 |
|---|---|---|
| LBT-POL-003 | Result authorisation and release | Policy |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on ISO 15189:2022 Medical laboratories: requirements for quality and competence, ISO 9001:2015 for supplier control, and the Global Patient Safety Action Plan 2021–2030 for critical results. |
| 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)