Standards › Standard 11 › Policies
Policy · PRO-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 11 (Procedure Units), criterion 11.1, 11.10
At a glance
- Before each procedure the patient is assessed on the record (PRO-FRM-001): history, current medicines, allergies and pregnancy.
- Anticoagulants and supplements are recorded and reviewed before the procedure.
- A procedure is not started if a contraindication is found and not resolved.
- Each assessment is signed by the practitioner before the procedure.
- Stop and get help straight away if: a procedure starts with no pre-procedure assessment, or with a contraindication not resolved and recorded.
1. Purpose
To make sure each patient is suitable for the procedure before it starts (11.1, 11.10).
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 each patient is suitable for the procedure before it starts (11.1, 11.10).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Responsible practitioner | Assesses and signs each patient | Clinician |
| Nurse | Checks medicines and allergies on the record | 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. Assess.
- Complete PRO-FRM-001 before the procedure: history, medicines, allergies, pregnancy and conditions.
Key point: Before, every time.
Step 2. Check the risks.
- Review anticoagulants and supplements, and decide with the practitioner whether to proceed or defer.
Key point: Decision recorded.
Step 3. Sign.
- Sign the assessment before the procedure starts.
Key point: Signed before.
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 |
|---|---|---|---|---|
| Procedures with a signed pre-procedure assessment | 100% | Monthly | Medical director | Escalate to chief executive |
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 |
|---|---|---|
| PRO-FRM-001 | Pre-procedure assessment record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the ASF Expert Committee consensus and the WHO Guidelines for Safe Surgical Care and Safe Procedures (2009). |
| 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)