Standards › Standard 55 › Standard operating procedures (SOPs)
SOP · PLS-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 55.1
At a glance
- Every patient has a documented assessment of suitability before surgery (PLS-FRM-001).
- The assessment covers medical conditions, medicines, smoking, body weight, and expectations.
- A patient who is unsuitable, or whose expectations are not realistic, is not booked until the issue is resolved.
- The surgeon signs the assessment and the decision.
- Stop and get help straight away if: surgery is booked for a patient with no recorded suitability assessment.
1. Purpose
To make sure only suitable patients with realistic expectations go to surgery (55.1).
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 only suitable patients with realistic expectations go to surgery (55.1).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Surgeon | Carries out and signs the suitability assessment | Clinical lead |
| Pre-admission nurse | Records the history and checks the medicines | Surgeon |
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. Assess.
- Assess medical conditions, medicines, smoking, weight and expectations (PLS-FRM-001).
Key point: Assessed.
Step 2. Decide.
- Decide suitability and record it. Do not book an unsuitable patient until the issue is resolved.
Key point: Decided.
Step 3. Sign.
- The surgeon signs the assessment before the date of surgery.
Key point: Signed.
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 |
|---|---|---|---|---|
| Patients with a signed assessment before surgery | 100% | Monthly | Clinical lead | Cancel the booking |
| Assessments that record expectations | 100% | Monthly | Clinical lead | Repeat the assessment |
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 |
|---|---|---|
| PLS-FRM-001 | Suitability assessment record | Record |
| CLN-SOP-005 | VTE risk assessment and prophylaxis (existing, reused) | SOP |
17. Evidence
| Reference | Note |
|---|---|
| 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
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)