Standards › Standard 13 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · MOB-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 13 (Mobile Clinic and Outreach), criterion 13.6
At a glance
- Consent is obtained before each treatment, as CON-SOP-001 sets out.
- Privacy is protected at each site as far as the conditions allow, with a screen or a separate space.
- A patient who cannot speak for themselves is supported by a named person, with the reason recorded.
- Information is shared only with the patient’s agreement.
- Stop and get help straight away if: a treatment is given with no consent, or a patient is examined in the open with no privacy and no reason recorded.
1. Purpose
To respect consent and privacy in homes and open settings (13.6).
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
To respect consent and privacy in homes and open settings (13.6).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinician | Obtains consent and protects privacy | Clinician |
| Team leader on the day | Sets up the space | 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. Consent.
- Obtain consent before each treatment, recorded on CON-FRM-001.
Key point: Before each treatment.
Step 2. Privacy.
- Set up a screen or separate space at each site, and record where none was possible.
Key point: As far as conditions allow.
Step 3. Share.
- Share information only with the patient’s agreement.
Key point: With agreement.
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 |
|---|---|---|---|---|
| Treatments with consent recorded | 100% | Monthly | Outreach lead | 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 |
|---|---|---|
| CON-FRM-001 | Consent record (existing, reused) | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the Sphere Handbook, Humanitarian Charter and Minimum Standards in Humanitarian Response (2018). |
| 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)