Standards › Standard 33 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · LBT-SOP-010 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 33.6
At a glance
- Each test states its indication, its limitations and the preparation needed (LBT-FRM-002).
- The information is in the test catalogue and on the request form.
- The clinician receives the information at the point of request.
- Patient preparation is given in writing where needed.
- Stop and get help straight away if: a test that needs patient preparation is requested with no instructions given.
1. Purpose
To make sure clinicians and patients understand what each test is for, what it cannot show, and how to prepare (33.6).
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 clinician who orders a test without knowing what it can and cannot tell them will misread the result. Clear written information on each test’s purpose and limits is part of a safe result.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Senior scientist | Writes and updates the test information | Laboratory director |
| Clinic and reception staff | Give the patient the preparation instructions | 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. Write.
- Write the indication, limitation and preparation for each test.
Key point: Written.
Step 2. Publish.
- Publish the information in the catalogue and on the request form (LBT-FRM-002).
Key point: Published.
Step 3. Give.
- Give the patient the written preparation instructions at the point of request.
Key point: Given.
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 |
|---|---|---|---|---|
| Tests with information published | 100% | Annual | 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-FRM-002 | Test request information sheet | Form |
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)