Standards › Standard 52 › Standard operating procedures (SOPs)
SOP · PSY-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 52.4
At a glance
- Medicines with significant interaction risk or specific monitoring needs are managed under this protocol.
- Each prescription is checked for interactions before it starts (HOS-POL-001).
- Monitoring tests are set for each medicine and recorded (PSY-FRM-003).
- The protocol is reviewed each year.
- Stop and get help straight away if: a psychiatric medicine with a required monitoring test is given without a test scheduled.
1. Purpose
To make sure psychiatric medicines with interaction risk or required monitoring are checked and monitored (52.4).
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
Some psychiatric medicines interact with others or need careful monitoring, such as blood tests. A defined process for these keeps the treatment safe.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Responsible psychiatrist | Prescribes and sets the monitoring plan | Clinical lead |
| Ward pharmacist | Checks interactions and tracks the monitoring | Clinical lead |
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.
- Check each prescription for interactions and record the result.
Key point: Checked.
Step 2. Plan.
- Set the monitoring test and date for each medicine that requires it.
Key point: Planned.
Step 3. Monitor.
- Carry out and record each monitoring test (PSY-FRM-003).
Key point: Monitored.
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 |
|---|---|---|---|---|
| Prescriptions checked for interactions | 100% | Monthly | Ward pharmacist | Escalate to the responsible psychiatrist |
| Monitoring tests done on schedule | 100% | Monthly | Ward pharmacist | Escalate to the 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 |
|---|---|---|
| PSY-FRM-003 | Psychiatric medicine monitoring record | Record |
| HOS-POL-001 | Medicines management policy (existing, reused) | Policy |
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)