Standards › Standard 16 › Policies
Policy · PED-POL-003 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 16.7
At a glance
- Child health checks and immunisations follow the written schedule, checked each year against the national schedule in force.
- Each child seen in primary care is checked against the schedule at each contact and recorded on PED-REG-003.
- A missed check or dose is followed up within the set time (PED-SOP-002).
- A child who is not followed up is not left off the schedule.
- Stop and get help straight away if: a child’s immunisation is missed with no follow-up.
1. Purpose
To make sure each child receives the checks and immunisations due for their age (16.7).
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
Immunisation and child health checks catch illness early and prevent serious disease. Following a schedule, and recording each check, keeps children on track.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead for primary care | Owns the schedule and the follow-up rule | Clinician |
| Nurse or doctor | Checks the schedule at each contact and records it | Clinician |
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 the schedule.
- Check the child against the written schedule at each contact.
Key point: Checked each contact.
Step 2. Follow up.
- Book and record any missed check or dose (PED-SOP-002).
Key point: Booked.
Step 3. Record.
- Record each item given, missed or followed up on PED-REG-003.
Key point: 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 |
|---|---|---|---|---|
| Children with immunisations up to date for age | 95% | Quarterly | Clinical lead for primary care | 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 |
|---|---|---|
| PED-REG-003 | Child health schedule register | Register |
| PED-SOP-002 | Immunisation and child health follow-up | Procedure |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Pocket book of hospital care for children (2013) and the UN Convention on the Rights of the Child (1989). |
| 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.
Planned course: Immunisation and child health checks. New course planned.
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)