Standards › Standard 13 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · MOB-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 13 (Mobile Clinic and Outreach), criterion 13.10
At a glance
- A member of staff who works alone, or a team out of contact with the base, checks in at a set time.
- The check-in is recorded on MOB-FRM-004.
- If a check-in is missed, the response starts at once: a call, then the named person, then the emergency service.
- The response is recorded.
- Stop and get help straight away if: a check-in is missed and no response starts.
1. Purpose
To make sure someone notices if a lone worker is hurt or unwell in the field (13.10).
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 make sure someone notices if a lone worker is hurt or unwell in the field (13.10).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Outreach lead | Owns the check-in rule and the response | Clinician |
| Named base contact | Receives the check-ins and starts the response | 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. Check in.
- Check in at the set time, and record it on MOB-FRM-004.
Key point: At the set time.
Step 2. Respond.
- If a check-in is missed, call the worker, then the named person, then the emergency service.
Key point: Call, named person, emergency.
Step 3. Record.
- Record the missed check-in, the response and the outcome.
Key point: Every response recorded.
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 |
|---|---|---|---|---|
| Check-ins made on time | 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 |
|---|---|---|
| MOB-FRM-004 | Lone working check-in log | Log |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on WHO classification and minimum standards for emergency medical teams (2013). |
| 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)