Standards › Standard 3 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · MNP-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 3.3
At a glance
- Use one validated scale for each patient group, and use it the same way each time.
- Record the score, the time and the location of the pain.
- Reassess after each intervention and at the set interval.
- Tell the responsible clinician when a score does not fall.
- Stop and get help straight away if: a patient has no pain score for more than the set interval, or a high score is not reported.
1. Purpose
To assess and reassess pain in the same structured way for every patient (3.3).
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 asked about once on admission is quickly forgotten. Assessing it with a structured tool, and again after treatments, shows whether the treatment is working and when it must change.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Ward nurse | Assesses and reassesses | Nurse |
| Senior nurse | Checks the charts each shift | 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. Choose the tool.
- Use the scale set for the patient’s group, such as a numeric rating scale for adults who can self-report.
Key point: The same tool each time.
Step 2. Record.
- Record the score on the chart at each check.
Key point: Scores on the chart.
Step 3. Reassess and report.
- Reassess after each intervention and report a score that does not fall.
Key point: Check after every treatment.
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 |
|---|---|---|---|---|
| Pain scores recorded at set intervals | At least 90% | Monthly | Ward manager | 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 |
|---|---|---|
| MNP-FRM-002 | Pain assessment chart | Chart |
| MNP-POL-003 | Pain assessment and management | Policy |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on Ferreira-Valente et al. (2011) on validated pain intensity scales. |
| 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)