Standards › Standard 21 › Standard operating procedures (SOPs)
Procedure · URG-SOP-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 21.7
At a glance
- Re-check each patient waiting to be seen at the set interval, and record it (URG-FRM-004).
- If a patient’s condition changes while waiting, reassess at once.
- If a patient is deteriorating, escalate at once to the clinician on duty.
- Record each re-check and its outcome.
- Stop and get help straight away if: a patient waits three hours with no re-check.
1. Purpose
To make sure a patient who deteriorates while waiting is found and escalated (21.7).
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
A patient waiting to be seen can deteriorate without anyone noticing. Re-checking each waiting patient at a set interval, and recording it, catches the patient who is getting worse before it is too late.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Triage nurse | Re-checks waiting patients and escalates | Clinician |
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. Re-check.
- Re-check each waiting patient at the set interval.
Key point: Re-checked.
Step 2. Reassess or escalate.
- Reassess at once if the condition changes. Escalate if the patient is deteriorating.
Key point: Acted on.
Step 3. Record.
- Record each re-check and its outcome on URG-FRM-004.
Key point: Recorded.
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 |
|---|---|---|---|---|
| Waiting patients re-checked at the set interval | 100% | Monthly | Clinical lead | Escalate to medical director |
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 |
|---|---|---|
| URG-FRM-004 | Waiting-room re-check record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Emergency triage, assessment and treatment (ETAT) manual (2005) and the WHO Emergency care systems for universal health coverage (2016). |
| 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.
Planned course: Waiting-room re-checks and deterioration. New course planned.
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)