Standards › Standard S3 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · PHC-SOP-006 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S3 (Primary care practice), criterion S3.7
At a glance
- Offer screening to every eligible patient, and record the offer.
- Follow up every abnormal result to a clear outcome.
- Track uptake over time.
- Report uptake to the practice meeting each year.
- Stop and get help straight away if: an abnormal screening result has no follow-up recorded.
1. Purpose
To make screening work: offered, followed up to an outcome, and measured (S3.7).
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
Screening saves lives only if people are offered it and results reach a clear outcome. Tracking uptake shows whether the offer works.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Screening lead | Runs the offer and the follow-up | Clinician |
| Reception | Records the offer and the decline | Trained |
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. Offer.
- Invite eligible patients in the screening programme.
- Record the offer and any decline.
Key point: Every eligible patient is offered.
Step 2. Follow up.
- For each abnormal result, arrange follow-up and record the outcome.
Key point: Result without outcome is a failure.
Step 3. Measure.
- Calculate uptake each year and record it.
Key point: Uptake shows if the offer works.
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 |
|---|---|---|---|---|
| Eligible patients offered screening | At least 70% | Yearly | Screening lead | Escalate to clinical lead |
| Abnormal results with outcome | 100% | Quarterly | Screening lead | Escalate to clinical lead |
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 |
|---|---|---|
| PHC-REG-005 | Screening register | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Eligibility and intervals to follow national screening programme. |
| 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)