Standards › Standard 14 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · OHS-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 14 (Occupational Health), criterion 14.3
At a glance
- Each hazard that needs surveillance is listed, with its interval (noise, chemicals, manual handling and others).
- Each exposed worker is on the surveillance schedule (OHS-REG-002).
- Results are recorded at each interval, and an abnormal result is reviewed within the set time.
- A worker who leaves the hazard keeps the record.
- Stop and get help straight away if: an exposed worker is off the schedule, or an abnormal surveillance result is not reviewed.
1. Purpose
To catch slow harm from workplace hazards at set intervals, before symptoms (14.3).
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
Workers exposed to noise, chemicals or dust can be harmed slowly, without symptoms at first. Health checks on a schedule find the harm early, while it can still be stopped.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Occupational physician | Owns the schedule and the hazard list | Clinician |
| Occupational health nurse | Runs the surveillance and records results | 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. List the hazards.
- Name each hazard and its surveillance interval.
Key point: Each hazard, each interval.
Step 2. Enrol each worker.
- Put each exposed worker on the schedule in OHS-REG-002.
Key point: Every exposed worker.
Step 3. Review.
- Review each abnormal result within the set time and act on it.
Key point: Abnormal reviewed in time.
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 |
|---|---|---|---|---|
| Exposed workers on schedule | 100% | Quarterly | Occupational physician | Escalate to medical 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 |
|---|---|---|
| OHS-REG-002 | Health surveillance register | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on ILO Convention No. 161 concerning Occupational Health Services (1985) and the WHO Healthy Workplaces framework (2010). |
| 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
No e-learning course is linked to this document yet.
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)