Accréditation Sans Frontières

International Accreditation of Healthcare Facilities

ISO 9001 Ready · Ambulatory Clinic

163 documents, bilingual — every one downloadable

Blank masters, free for any healthcare organization. Or let ASF generate them with your names and logo through the intake.

79 procedures · 82 forms · index and audit · 76 universal, the rest by module · full package 43 MB

The line that never moves. ASF prepares organizations for ISO 9001. ASF does not certify them. The ISO 9001 certificate is issued by an independent, accredited certification body of the organization’s choice.

ASF supports healthcare organizations first and sells second. Every document in this library is free to download as a blank master, in English and Georgian, under CC BY-NC-SA 4.0: a clinic that wants to fill in the placeholders by hand may do so. What ASF sells is what most organizations do not have time for — the pack generated with their names, dates and logo after an expert review of the intake, the training, the assessments, the consultancy and the platform that runs it. The documents themselves belong to everyone.

Download the full package — all documents, EN + KA (zip) ↓Master document index (Excel) ↓

Master Index · 3

Code Title Type Included when Download
AUDIT-01 Full Pack Quality Audit Report SOP/Policy Always EN · KA
INDEX Records & Forms Index Index Always EN · KA
MAP-01 Master Index & Document Map SOP/Policy Always EN · KA

Tier 2 – Governance · 23

Code Title Type Included when Download
GOV-01 Nonconformity & Corrective Action SOP/Policy Always EN · KA
GOV-01-F01 Nonconformity Report Form Always EN · KA
GOV-01-F02 Corrective Action Plan (CAPA) Form Always EN · KA
GOV-02 Internal Audit Program SOP/Policy Always EN · KA
GOV-02-F01 Internal Audit Checklist Form Always EN · KA
GOV-02-F02 Audit Finding Log Form Always EN · KA
GOV-03 Management Review SOP/Policy Always EN · KA
GOV-03-F01 Management Review Minutes Form Always EN · KA
GOV-03-F02 Management Review Action Item Tracker Form Always EN · KA
GOV-04 Document Control SOP/Policy Always EN · KA
GOV-04-F01 Document Control Register Form Always EN · KA
GOV-04-F02 Document Change Request Form Form Always EN · KA
GOV-05 Risk Register SOP/Policy Always EN · KA
GOV-05-F02 Risk Assessment Worksheet Form Always EN · KA
GOV-06 GDPR Data Protection Policy SOP/Policy Always EN · KA
GOV-06-F01 Data Subject Rights Request Log Form Always EN · KA
GOV-07 Cybersecurity & IT Security Policy SOP/Policy Always EN · KA
GOV-07-F01 Cybersecurity/IT Security Incident Report Form Always EN · KA
GOV-08 Conflict of Interest Policy SOP/Policy Always EN · KA
GOV-08-F01 Annual Disclosure & Attestation Form (COI / Anti-Bribery / Whistleblower Awareness) Form Always EN · KA
GOV-09 Anti-Bribery & Anti-Corruption Policy SOP/Policy Always EN · KA
GOV-10 Whistleblower Protection Policy SOP/Policy Always EN · KA
GOV-11 Regulatory Crosswalk & Multi-Jurisdiction Equivalence Reference SOP/Policy Always EN · KA

Tier 3 – General Clinical / IPC / Patient Safety / HIM / HR · 31

Code Title Type Included when Download
SOP-HIM-01 Patient Records Confidentiality SOP/Policy Always EN · KA
SOP-HIM-01-F01 Medical Record Amendment Request Form Always EN · KA
SOP-HIM-01-F02 Release of Information Authorization Form Always EN · KA
SOP-HR-01 Physician & Clinical Staff Credentialing SOP/Policy Always EN · KA
SOP-HR-01-F01 Physician Credentialing Checklist Form Always EN · KA
SOP-HR-01-F02 Privileging Request Form Form Always EN · KA
SOP-HR-03 Volunteer, Student & Trainee Supervision SOP/Policy Always EN · KA
SOP-HR-03-F01 Volunteer/Student/Trainee Supervision Agreement & Checklist Form Always EN · KA
SOP-IPC-01 Standard Precautions SOP/Policy Always EN · KA
SOP-IPC-01-F01 Hand Hygiene Audit Checklist Form Always EN · KA
SOP-IPC-02 Hand Hygiene SOP/Policy Always EN · KA
SOP-IPC-03 Personal Protective Equipment SOP/Policy Always EN · KA
SOP-IPC-07 Safe Injection Practices SOP/Policy Always EN · KA
SOP-IPC-08 Sharps Safety SOP/Policy Always EN · KA
SOP-IPC-08-F01 Sharps Injury Log Form Always EN · KA
SOP-IPC-09 Post-Exposure Prophylaxis (Needlestick/Bloodborne) SOP/Policy Always EN · KA
SOP-IPC-09-F01 Post-Exposure Prophylaxis Incident Report Form Always EN · KA
SOP-MED-01 Medication Management SOP/Policy Always EN · KA
SOP-MED-01-F01 Medication Error Report Form Always EN · KA
SOP-MED-01-F02 High-Alert Medication Double-Check Log Form Always EN · KA
SOP-MED-02 Controlled Substances Security & Diversion Prevention SOP/Policy Controlled substances EN · KA
SOP-MED-02-F01 Controlled Substance Inventory & Count Log Form Controlled substances EN · KA
SOP-PR-01 General Informed Consent SOP/Policy Always EN · KA
SOP-PR-01-F01 General Informed Consent Form Form Always EN · KA
SOP-PS-01 Patient Identification SOP/Policy Always EN · KA
SOP-PS-01-F01 Patient Identification Verification Checklist Form Always EN · KA
SOP-PS-02 Clinical Incident & Adverse Event Reporting SOP/Policy Always EN · KA
SOP-PS-02-F01 Clinical Incident / Adverse Event Report Form Always EN · KA
SOP-STR-01 Instrument Reprocessing & Sterilization SOP/Policy Sterilization EN · KA
SOP-STR-01-F01 Sterilization Cycle Log (BI/CI Results) Form Sterilization EN · KA
SOP-STR-01-F02 Instrument Tray Content Checklist Form Sterilization EN · KA

Tier 3 – Patient Rights · 10

Code Title Type Included when Download
PR-01 Patient Rights SOP/Policy Always EN · KA
PR-02 Interpreter Language Access SOP/Policy Always EN · KA
PR-02-F01 Interpreter Use Log Form Always EN · KA
PR-03 Religious Dietary Accommodation Policy SOP/Policy Always EN · KA
PR-03-F01 Patient Accommodation Request Form Always EN · KA
PR-04 Advance Directives Resuscitation Status Policy SOP/Policy Always EN · KA
PR-04-F01 Advance Directive Documentation Form Always EN · KA
PR-05 Accessibility Disability Access Policy SOP/Policy Always EN · KA
PR-05-F01 Accessibility Accommodation Request Form Always EN · KA
PR-06 Migrant Refugee Inclusive Care SOP/Policy Always EN · KA

Tier 4 – Laboratory & Diagnostics · 37

Code Title Type Included when Download
SOP-LAB-01 Specimen Collection & Chain of Custody SOP/Policy In-house laboratory EN · KA
SOP-LAB-01-F01 Specimen Collection Label/Requisition Form In-house laboratory EN · KA
SOP-LAB-02 Laboratory Internal Quality Control SOP/Policy In-house laboratory EN · KA
SOP-LAB-02-F01 Daily Internal QC Log Form In-house laboratory EN · KA
SOP-LAB-02-F02 QC Out-of-Range Investigation Form Form In-house laboratory EN · KA
SOP-LAB-03 Specimen Rejection Criteria SOP/Policy In-house laboratory EN · KA
SOP-LAB-03-F01 Specimen Rejection Log Form In-house laboratory EN · KA
SOP-LAB-04 Diagnostic Imaging Quality Assurance SOP/Policy Diagnostic imaging EN · KA
SOP-LAB-04-F01 Imaging Equipment QA Checklist Form Diagnostic imaging EN · KA
SOP-LAB-05 Point-of-Care Testing Governance SOP/Policy In-house laboratory EN · KA
SOP-LAB-05-F01 POCT Device Competency Checklist Form In-house laboratory EN · KA
SOP-LAB-05-F02 POCT Daily QC Log Form In-house laboratory EN · KA
SOP-LAB-06 Reference Laboratory & Send-Out Testing SOP/Policy In-house laboratory EN · KA
SOP-LAB-06-F01 Chain of Custody Form (Specimen Send-Out) Form In-house laboratory EN · KA
SOP-LAB-07 Laboratory Equipment Calibration & Maintenance SOP/Policy In-house laboratory EN · KA
SOP-LAB-07-F01 Equipment Calibration/Maintenance Log Form In-house laboratory EN · KA
SOP-LAB-07-F02 Calibration Verification Record Form In-house laboratory EN · KA
SOP-LAB-08 Reagent & Consumable Management SOP/Policy In-house laboratory EN · KA
SOP-LAB-08-F01 Reagent/Consumable Lot Receipt Log Form In-house laboratory EN · KA
SOP-LAB-09 Result Reporting, Verification & Amendment SOP/Policy In-house laboratory EN · KA
SOP-LAB-09-F01 Result Amendment Record Form In-house laboratory EN · KA
SOP-LAB-10 Laboratory Biosafety & Biohazardous Waste SOP/Policy In-house laboratory EN · KA
SOP-LAB-10-F01 Biohazard Waste Manifest Tracking Log Form In-house laboratory EN · KA
SOP-LAB-11 Laboratory Personnel Competency Assessment SOP/Policy In-house laboratory EN · KA
SOP-LAB-11-F01 Six-Element Competency Assessment Checklist Form In-house laboratory EN · KA
SOP-LAB-12 Clinical Microbiology Testing SOP/Policy In-house laboratory EN · KA
SOP-LAB-12-F01 Gram Stain/Culture Worksheet Form In-house laboratory EN · KA
SOP-LAB-13 Molecular (PCR) Testing SOP/Policy In-house laboratory EN · KA
SOP-LAB-13-F01 PCR Negative Control / Contamination Log Form In-house laboratory EN · KA
SOP-LAB-14 Test Menu & Scope of Testing SOP/Policy In-house laboratory EN · KA
SOP-LAB-15 Method Validation & Verification SOP/Policy In-house laboratory EN · KA
SOP-LAB-15-F01 Method Validation/Verification Report Template Form In-house laboratory EN · KA
SOP-LAB-16 Laboratory Data Integrity SOP/Policy In-house laboratory EN · KA
SOP-LAB-16-F01 Audit Trail Review Checklist Form In-house laboratory EN · KA
SOP-LAB-16-F02 Backup/Restore Test Log Form In-house laboratory EN · KA
SOP-LAB-17 Critical Lab Value Notification SOP/Policy In-house laboratory EN · KA
SOP-LAB-17-F01 Critical Value Notification Log Form In-house laboratory EN · KA

Tier 5 – Oncology · 16

Code Title Type Included when Download
ONC-01 Hazardous Drug Handling & Safety SOP/Policy Oncology EN · KA
ONC-01-F01 Hazardous Drug Spill Report Form Oncology EN · KA
ONC-02 Extravasation Management SOP/Policy Oncology EN · KA
ONC-02-F01 Extravasation Event Report Form Oncology EN · KA
ONC-03 Oncology-Specific Informed Consent SOP/Policy Oncology EN · KA
ONC-03 Oncology-Specific Informed Consent SOP/Policy Oncology EN · KA
ONC-03-F01 Oncology Informed Consent (with Fertility Discussion) Form Oncology EN · KA
ONC-04 Cytotoxic Waste Disposal SOP/Policy Oncology EN · KA
ONC-04-F01 Cytotoxic Waste Manifest Form Oncology EN · KA
ONC-05 Neutropenic Fever Protocol SOP/Policy Oncology EN · KA
ONC-05-F01 Neutropenic Fever Recognition & Transfer Checklist Form Oncology EN · KA
ONC-06 Chemotherapy Order Verification SOP/Policy Oncology EN · KA
ONC-06-F01 Chemotherapy Order Verification Sheet (4-Point) Form Oncology EN · KA
ONC-06-F02 BSA Calculation Worksheet Form Oncology EN · KA
ONC-07 Central Venous Access Device (Port) Care SOP/Policy Oncology EN · KA
ONC-07-F01 Port Access/Flush Log Form Oncology EN · KA

Tier 6 – Pediatric · 8

Code Title Type Included when Download
PED-01 Pediatric Consent & Guardian Authorization SOP/Policy Pediatric patients EN · KA
PED-01-F01 Pediatric Consent/Assent Form Form Pediatric patients EN · KA
PED-02 Pediatric Dosing Safety SOP/Policy Pediatric patients EN · KA
PED-02-F01 Weight-Based Dosing Calculation Worksheet Form Pediatric patients EN · KA
PED-03 Safeguarding SOP/Policy Pediatric patients EN · KA
PED-03-F01 Safeguarding Concern Report Form Pediatric patients EN · KA
PED-04 Vaccine Cold Chain Management SOP/Policy Pediatric patients EN · KA
PED-04-F01 Vaccine Cold Chain Temperature Log Form Pediatric patients EN · KA

Tier C – Dialysis · 10

Code Title Type Included when Download
DIAL-01 Vascular Access Care SOP/Policy Dialysis EN · KA
DIAL-01-F01 Vascular Access Daily Assessment Log Form Dialysis EN · KA
DIAL-02 Water Treatment & Dialysate Quality SOP/Policy Dialysis EN · KA
DIAL-02-F01 Water/Dialysate Monthly Microbiological Test Log Form Dialysis EN · KA
DIAL-03 Dialyzer Use — Single-Use vs. Reprocessing SOP/Policy Dialysis EN · KA
DIAL-03-F01 Dialyzer Use Record Form Dialysis EN · KA
DIAL-04 Bloodborne Pathogen Segregation (Dialysis) SOP/Policy Dialysis EN · KA
DIAL-04-F01 HBsAg/HCV Testing Schedule Tracker Form Dialysis EN · KA
DIAL-05 Intradialytic Emergency Response SOP/Policy Dialysis EN · KA
DIAL-05-F01 Intradialytic Event Report Form Dialysis EN · KA

Tier 7 – Cross-Cutting · 25

Code Title Type Included when Download
CC-01 Emergency Preparedness SOP/Policy Always EN · KA
CC-01-F01 Emergency Drill Report Form Always EN · KA
CC-02 Supplier Evaluation SOP/Policy Always EN · KA
CC-02-F01 Supplier Evaluation Scorecard Form Always EN · KA
CC-03 Complaints Handling SOP/Policy Always EN · KA
CC-03-F01 Patient Complaint Intake Form Form Always EN · KA
CC-04 Business Continuity SOP/Policy Always EN · KA
CC-04-F01 Business Continuity Test Report Form Always EN · KA
CC-05 Environmental Cleaning & Disinfection SOP/Policy Always EN · KA
CC-05-F01 Terminal Cleaning Verification Checklist Form Always EN · KA
CC-06 Radiation Safety Program SOP/Policy Diagnostic imaging EN · KA
CC-06-F01 Radiation Dosimetry Log Form Diagnostic imaging EN · KA
CC-06-F02 Pre-Examination Pregnancy Determination Form Form Diagnostic imaging EN · KA
CC-07 Anaphylaxis / Acute Allergic Reaction Management SOP/Policy Always EN · KA
CC-07-F01 Anaphylaxis Event Report Form Always EN · KA
CC-08 General Facility & Fire Safety SOP/Policy Always EN · KA
CC-08-F01 Fire Drill Report Form Always EN · KA
CC-09 Medical Tourism & International Patient Coordination SOP/Policy International patients EN · KA
CC-09-F01 International Patient Intake & Coordination Form Form International patients EN · KA
CC-10 Continuity of Care for Returning/Relocating Patients SOP/Policy International patients EN · KA
CC-10-F01 Continuity-of-Care Summary Form International patients EN · KA
CC-11 Telehealth / Telemedicine SOP/Policy Telehealth EN · KA
CC-11-F01 Telehealth Informed Consent & Encounter Log Form Telehealth EN · KA
CC-12 Electrical Safety & Backup Power SOP/Policy Always EN · KA
CC-12-F01 Backup Power / Generator Test Log Form Always EN · KA

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