PNT-SOP-001: Reception health screening and medical examination

Standards › Standard 62 › Standard operating procedures (SOPs)

SOP · PNT-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 62.1

At a glance

Every person admitted to custody has a health screening on the day of admission (PNT-FRM-001).
A full medical examination is done within 24 hours by a named clinician.
Each positive finding has a documented plan and a named clinician.
Suicide and self-harm risk is screened on admission (PSY-SOP-001).
Stop and get help straight away if: a person is held in custody with no reception health screening, or a positive finding has no plan.

1. Purpose

To find health needs, infection risk and suicide risk as early as possible after admission (62.1).

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

Many people in custody have higher rates of infectious disease, mental illness, substance use and injury than the general population. The Nelson Mandela Rules (2015, Rule 30) require a medical examination on admission, and WHO Prisons and Health (2014) recommends a systematic reception screening so that needs are found early.

5. Responsibilities

Role	Responsibility	Competence
Clinician in custody	Carries out the examination and signs the plan	Clinical lead
Nurse in custody	Completes the screening record on the day of admission	Clinician in custody

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. Screen.

Complete the screening record on the day of admission (PNT-FRM-001).

Key point: Screened.

Step 2. Examine.

Carry out the full medical examination within 24 hours and name the clinician.

Key point: Examined.

Step 3. Plan.

Document a plan for each positive finding, and refer urgently where needed.

Key point: Planned.

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
Admissions with a screening on the day	100%	Monthly	Clinical lead	Escalate to the custody governor and the health authority
Examinations within 24 hours	95%	Monthly	Clinical lead	Review the reception process

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
PNT-FRM-001	Reception health screening record	Record
PSY-SOP-001	Suicide risk screening and continuous observation (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

Patient Identification, Informed Consent and Patient Rights (T-07)

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)

Download this document as PDF