Standards › ASF Health Standards V11 › Standard 10
Standard 10 (Pain Management), PDF
ASF-HS11-S10 · 1 November 2026 · 23 pages, A4. The same criteria as this page, for printing and assessors.
Where this standard applies
Standard 10 is a core standard. It applies to every facility type that treats pain or prescribes, stores or gives controlled medicines. The table shows each criterion by facility type, and a criterion is marked N/A where it does not apply to that type.
| Criterion | Hospital | Ambulatory clinic | Primary health clinic | Long-term care | Telemedicine | Home care | Fitness and wellness | Dental clinic | Aesthetic and procedure clinic |
|---|---|---|---|---|---|---|---|---|---|
| 10.1 Opioid Prescribing Is Deliberately Stewarded | Yes | Yes | Yes | Yes | N/A | Yes | N/A | Yes | N/A |
| 10.2 Pain Is Formally Assessed and Reassessed, Not Just Asked About Once | Yes | Yes | Yes | Yes | Yes | Yes | N/A | Yes | Yes |
| 10.3 Pain and Symptoms Are Assessed and Controlled | Yes | Yes | Yes | Yes | Yes | Yes | N/A | Yes | Yes |
| 10.4 Opioids and Controlled Medicines Are Managed Safely | Yes | Yes | Yes | Yes | N/A | Yes | N/A | Yes | N/A |
| 10.5 Patients and Families Are Informed About Their Pain Plan | Yes | Yes | Yes | Yes | Yes | Yes | N/A | Yes | Yes |
Pain Management
Pain is assessed, reassessed and controlled in every setting where patients have pain, and opioids and other controlled medicines are prescribed, stored and reviewed safely. Medicines safety in general is in Standard 8 (Medicines Safety).
Each criterion is shown in three settings: Humanitarian settings, Transition and fragile, and Standard. In standard settings, every criterion is Must.
Training colours: red means essential, green recommended, yellow optional. Each course shows its level for each setting: humanitarian, transition and fragile, and standard.
10.1
Opioid Prescribing Is Deliberately Stewarded
Humanitarian settings: MediumTransition and fragile: MediumStandard: Must
Opioid prescribing follows a written stewardship approach: appropriate starting dose and duration, consideration of non-opioid options first, and set review dates. Opioids are managed as a distinct risk, not as one more high-alert medicine.
Rating: Medium in humanitarian settings; Medium in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: telemedicine, fitness and wellness, aesthetic and procedure clinic.
Why it matters. Opioids relieve pain, but over-prescribing, long courses without review and missed warning signs cause harm. A written approach keeps the dose and duration to what the patient needs.
Questions the surveyor asks
- Is there a written opioid stewardship approach? It names the drugs, starting doses, review dates and non-opioid options.
- Is a physician champion or designated person responsible? Where no pharmacy function exists, one named person must own the approach.
- Are long-term and high-dose prescriptions reviewed? A review on a set date, recorded in the file.
How the surveyor verifies this criterion
Sample. The opioid policy, and a sample of 10 opioid prescriptions from the last 3 months with their review records.
1. Written approach exists
Method. Read the opioid policy for drugs, doses, review dates and non-opioid options.
Evidence to show. Opioid stewardship policy (MNP-POL-002).
Pass when. The policy covers all four elements and is signed off by the facility leadership.
2. Designated person is named
Method. Check the role assignment and the policy sign-off.
Evidence to show. Opioid prescribing review and diversion monitoring (MNP-SOP-001).
Pass when. A named person or physician champion is recorded in the policy.
3. Reviews are done and recorded
Method. Check each sampled prescription for a review record on the set date.
Evidence to show. Opioid prescribing review record (MNP-FRM-001).
Pass when. Every sampled long-term opioid prescription has a review recorded on schedule.
Immediate fail (any one means the criterion is not met)
- Opioids are prescribed with no written approach and no review.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. A written stewardship approach, a named owner, and recorded reviews on schedule.
Partial because. The approach exists but reviews are missing or not recorded for some prescriptions.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Prescriber (doctor) ISCO 2212 ASF proposal |
Writes the opioid plan, sets the review date and the stop date. | Humanitarian: Essential Transition: Essential Standard: Essential |
Prescribing & Controlled Substance Management (TM-05) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
MNP-SOP-001 MNP-FRM-001 |
| Clinical pharmacist ISCO 2262 ASF proposal |
Reviews each opioid prescription and monitors for misuse. | Humanitarian: Essential Transition: Essential Standard: Essential |
Prescribing & Controlled Substance Management (TM-05) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
MNP-POL-002 MNP-SOP-001 MNP-FRM-001 |
| Registered nurse ISCO 2221 ASF proposal |
Records the effect of each dose and reports concerns. | Humanitarian: Essential Transition: Essential Standard: Essential |
The Medication-Use Process (PS-10) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
— |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Prescribing & Controlled Substance Management (TM-05) GMJ Academy: English · Georgian |
Prescriber (doctor); Clinical pharmacist | Registered nurse |
| The Medication-Use Process (PS-10) GMJ Academy: English · Georgian |
Clinical pharmacist; Registered nurse | Prescriber (doctor) |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| MNP-POL-002 · Opioid stewardship policy Policy · To use opioids safely: effective for pain, short in duration, and not misused. |
Clinical pharmacist (ISCO 2262) | Chief pharmacist (ISCO 2262) | N/A | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| MNP-SOP-001 · Opioid prescribing review and diversion monitoring Procedure (SOP) · To keep opioid prescribing under review and to find misuse early. |
Clinical pharmacist (ISCO 2262) | Chief pharmacist (ISCO 2262) | Prescriber (doctor) (ISCO 2212) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| MNP-FRM-001 · Opioid prescribing review record Form (record) · Records the reason for an opioid, the alternatives considered, the dose, the review and the stop date. |
Prescriber (doctor) (ISCO 2212) | N/A | Prescriber (doctor) (ISCO 2212) | Clinical pharmacist (ISCO 2262) | Records officer (ISCO 4132) |
References
- World Health Organization (2025). WHO Guideline on Balanced National Controlled Medicines Policies to Ensure Medical Access and Safety. Used for: safe prescribing and control of opioids (10.1). https://news.gmj.ge/guideline/who-balanced-national-controlled-medicines-policies/
- Centers for Disease Control and Prevention (USA) (2022). Clinical Practice Guideline for Prescribing Opioids for Pain. Used for: starting, reviewing and stopping opioid prescriptions (10.1). https://news.gmj.ge/guideline/clinical-practice-guideline-for-prescribing-opioids-for-pain-united-states-2022/
10.2
Pain Is Formally Assessed and Reassessed, Not Just Asked About Once
Humanitarian settings: MustTransition and fragile: MustStandard: Must
Pain is assessed with an agreed tool on admission and reassessed at a set interval and after any change in condition or treatment. The result is recorded and used to change the plan.
Rating: Must in humanitarian settings; Must in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: fitness and wellness.
Why it matters. Pain is a vital sign that is easy to miss when it is only asked about once. Regular reassessment shows whether the treatment is working and catches new pain early.
Questions the surveyor asks
- Is an agreed pain assessment tool used? One tool for the facility, adapted for children and for patients who cannot speak.
- Is pain reassessed at a set interval? The interval is written in the plan and followed.
- Is the result used to change the plan? A score that changes nothing is not an assessment.
How the surveyor verifies this criterion
Sample. Twenty patient records from the last 3 months, including admissions and post-procedure patients.
1. Agreed tool is used
Method. Check each sampled record for the tool and its score.
Evidence to show. Pain assessment record (MNP-FRM-002).
Pass when. The agreed tool is recorded in every sampled record.
2. Reassessment is on schedule
Method. Check the reassessment entries against the set interval.
Evidence to show. Symptom assessment table (HSP-FRM-001).
Pass when. Pain is reassessed at the set interval in at least 18 of the 20 sampled records.
3. Result changes the plan
Method. Check that a change in score is followed by a change in treatment or a note.
Evidence to show. Symptom assessment and control policy (HSP-POL-001).
Pass when. A recorded change in plan follows each sampled change in score.
Immediate fail (any one means the criterion is not met)
- Pain is not assessed in the records at all.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. Pain assessed with the agreed tool, reassessed on schedule, and the result used in the plan.
Partial because. Pain is assessed once, or reassessments are not recorded.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Registered nurse ISCO 2221 ASF proposal |
Assesses and reassesses pain with a validated score. | Humanitarian: Essential Transition: Essential Standard: Essential |
End-of-Life & Palliative Care (LTC-06) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
MNP-FRM-002 HSP-FRM-001 |
| Prescriber (doctor) ISCO 2212 ASF proposal |
Reviews the pain assessment and changes the plan. | Humanitarian: Essential Transition: Essential Standard: Essential |
End-of-Life & Palliative Care (LTC-06) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
— |
| Clinical pharmacist ISCO 2262 ASF proposal |
Checks that the pain plan and its medicines match. | Humanitarian: Essential Transition: Essential Standard: Essential |
End-of-Life & Palliative Care (LTC-06) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
HSP-POL-001 |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| End-of-Life & Palliative Care (LTC-06) GMJ Academy: English · Georgian |
Registered nurse; Prescriber (doctor) | Clinical pharmacist |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| MNP-FRM-002 · Pain assessment record Form (record) · Records each pain score, its location, the intervention and the reassessment. |
Registered nurse (ISCO 2221) | N/A | Registered nurse (ISCO 2221) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| HSP-FRM-001 · Symptom assessment table Form (record) · Records the validated score for each symptom at each assessment, and the change to the plan. |
Registered nurse (ISCO 2221) | N/A | Registered nurse (ISCO 2221) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| HSP-POL-001 · Symptom assessment and control policy Policy · To assess and control the symptoms that cause most suffering in serious illness. |
Clinical pharmacist (ISCO 2262) | Chief pharmacist (ISCO 2262) | N/A | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
References
- World Health Organization (2019). Guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents. Used for: pain assessment and reassessment (10.2). https://news.gmj.ge/guideline/guidelines-for-the-pharmacological-and-radiotherapeutic-management-of-cancer-pain-in-adults-and-adolescents/
- World Health Organization (2023). Guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. Used for: pain assessment in non-cancer pain (10.2). https://news.gmj.ge/guideline/guideline-for-non-surgical-management-of-chronic-primary-low-back-pain-in-adults-in-primary-and-community-care-settings/
10.3
Pain and Symptoms Are Assessed and Controlled
Humanitarian settings: MediumTransition and fragile: MustStandard: Must
Pain and other symptoms are assessed and controlled with a written plan, including a plan for breakthrough pain and an out-of-hours route for advice.
Rating: Medium in humanitarian settings; Must in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: fitness and wellness.
Why it matters. Uncontrolled pain and symptoms cause distress and can lead to unplanned admissions. A written plan lets any clinician on shift act safely.
Questions the surveyor asks
- Is there a written symptom plan for each patient in pain? The plan covers the first-line drug, the breakthrough dose and the review.
- Is there a plan for breakthrough pain? Staff know what to give and when to call.
- Can staff get advice out of hours? A named route, not an informal call to whoever is nearby.
How the surveyor verifies this criterion
Sample. Ten patient plans from the last 3 months, and the out-of-hours advice log.
1. Symptom plan is written
Method. Check each sampled plan for the first-line drug, breakthrough dose and review.
Evidence to show. Symptom assessment and control policy (HSP-POL-001).
Pass when. A written plan is in place for each sampled patient in pain.
2. Breakthrough plan exists
Method. Check the plan for a breakthrough dose and a call point.
Evidence to show. Symptom assessment table (HSP-FRM-001).
Pass when. Every sampled plan includes a breakthrough dose and a call point.
3. Out-of-hours advice is available
Method. Check the advice log and the out-of-hours route.
Evidence to show. Out-of-hours symptom advice (HSP-SOP-004).
Pass when. A named route is in place, and advice calls are logged.
Immediate fail (any one means the criterion is not met)
- Patients in pain have no plan and no out-of-hours route.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. Written symptom plans with breakthrough cover, and a working out-of-hours advice route.
Partial because. Plans are written for some patients, or the out-of-hours route is not logged.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Registered nurse ISCO 2221 ASF proposal |
Assesses symptoms at each review and records them. | Humanitarian: Essential Transition: Essential Standard: Essential |
End-of-Life & Palliative Care (LTC-06) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
HSP-FRM-001 HSP-SOP-004 |
| Prescriber (doctor) ISCO 2212 ASF proposal |
Prescribes for symptoms and reviews the response. | Humanitarian: Essential Transition: Essential Standard: Essential |
End-of-Life & Palliative Care (LTC-06) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
— |
| Clinical pharmacist ISCO 2262 ASF proposal |
Advises on symptom medicines and gives out-of-hours advice. | Humanitarian: Essential Transition: Essential Standard: Essential |
Medication Management & Family Coordination (HC-04) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
HSP-POL-001 HSP-SOP-004 |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| End-of-Life & Palliative Care (LTC-06) GMJ Academy: English · Georgian |
Registered nurse; Prescriber (doctor) | Clinical pharmacist |
| Medication Management & Family Coordination (HC-04) GMJ Academy: English · Georgian |
Registered nurse | Clinical pharmacist |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| HSP-POL-001 · Symptom assessment and control policy Policy · To assess and control the symptoms that cause most suffering in serious illness. |
Clinical pharmacist (ISCO 2262) | Chief pharmacist (ISCO 2262) | N/A | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| HSP-FRM-001 · Symptom assessment table Form (record) · Records the validated score for each symptom at each assessment, and the change to the plan. |
Registered nurse (ISCO 2221) | N/A | Registered nurse (ISCO 2221) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| HSP-SOP-004 · Out-of-hours symptom advice Procedure (SOP) · To give a named, reachable clinician for symptom crises at any hour. |
Clinical pharmacist (ISCO 2262) | Chief pharmacist (ISCO 2262) | Registered nurse (ISCO 2221) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
References
- World Health Organization (2019). Integrating palliative care and symptom relief into primary health care. Used for: symptom assessment and control (10.3). https://news.gmj.ge/guideline/integrating-palliative-care-and-symptom-relief-into-primary-health-care/
- World Health Organization (2021). Quality health services and palliative care: practical approaches and resources to support policy, strategy and practice. Used for: symptom control in serious illness (10.3). https://news.gmj.ge/guideline/quality-health-services-and-palliative-care-practical-approaches-and-resources-to-support-policy-strategy-and-practice/
10.4
Opioids and Controlled Medicines Are Managed Safely
Humanitarian settings: MustTransition and fragile: MustStandard: Must
Controlled medicines are stored securely, recorded in a register, counted at each handover with two signatures, and checked for diversion. Any discrepancy is investigated and reported.
Rating: Must in humanitarian settings; Must in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: telemedicine, fitness and wellness, aesthetic and procedure clinic.
Why it matters. Opioids are high-risk for misuse and diversion. A register and a double count are the simplest way to detect a loss.
Questions the surveyor asks
- Is there a register for all controlled medicines? Every receipt, supply and administration is recorded.
- Is each count double-signed? Two people count, and both sign.
- Are discrepancies investigated? A difference between the register and the stock is an incident.
How the surveyor verifies this criterion
Sample. The controlled drugs register and count sheets for the last 3 months, and the diversion checks.
1. Register is complete
Method. Check the register against the stock and the prescriptions.
Evidence to show. Controlled drugs register (HOS-REG-001).
Pass when. Every entry is complete, and the balance matches the stock.
2. Counts are double-signed
Method. Check the count sheets for two signatures at each handover.
Evidence to show. Opioid prescribing review and diversion monitoring (MNP-SOP-001).
Pass when. Every sampled count is signed by two people.
3. Discrepancies are investigated
Method. Check the incident log for any discrepancy.
Evidence to show. Opioid prescribing review record (MNP-FRM-001).
Pass when. Each discrepancy has a recorded investigation and outcome.
Immediate fail (any one means the criterion is not met)
- A controlled medicine is missing and not reported.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. A complete register, double-signed counts, and every discrepancy investigated.
Partial because. The register is kept but counts are done by one person, or discrepancies are not investigated.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Clinical pharmacist ISCO 2262 ASF proposal |
Keeps the controlled drugs register checked and counted. | Humanitarian: Essential Transition: Essential Standard: Essential |
Prescribing & Controlled Substance Management (TM-05) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
HOS-REG-001 MNP-SOP-001 MNP-FRM-001 |
| Prescriber (doctor) ISCO 2212 ASF proposal |
Reviews every opioid prescription at its review date. | Humanitarian: Essential Transition: Essential Standard: Essential |
High-Alert Medication Safety (PS-03) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
MNP-SOP-001 MNP-FRM-001 |
| Registered nurse ISCO 2221 ASF proposal |
Counts controlled drugs at each shift change. | Humanitarian: Essential Transition: Essential Standard: Essential |
High-Alert Medication Safety (PS-03) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
HOS-REG-001 |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Prescribing & Controlled Substance Management (TM-05) GMJ Academy: English · Georgian |
Prescriber (doctor); Clinical pharmacist | Registered nurse |
| High-Alert Medication Safety (PS-03) GMJ Academy: English · Georgian |
Registered nurse; Clinical pharmacist | Prescriber (doctor) |
| Addiction Medicine & Controlled Substances (AMB-21, Georgian version only) GMJ Academy: Georgian |
Prescriber (doctor) | Registered nurse |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| HOS-REG-001 · Controlled drugs register Register · Records every receipt, supply and administration of a controlled drug, with a count at each shift change. |
Records officer (ISCO 4132) | Chief pharmacist (ISCO 2262) | Registered nurse (ISCO 2221) | Clinical pharmacist (ISCO 2262) | Records officer (ISCO 4132) |
| MNP-SOP-001 · Opioid prescribing review and diversion monitoring Procedure (SOP) · To keep opioid prescribing under review and to find misuse early. |
Clinical pharmacist (ISCO 2262) | Chief pharmacist (ISCO 2262) | Prescriber (doctor) (ISCO 2212) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| MNP-FRM-001 · Opioid prescribing review record Form (record) · Records the reason for an opioid, the alternatives considered, the dose, the review and the stop date. |
Prescriber (doctor) (ISCO 2212) | N/A | Prescriber (doctor) (ISCO 2212) | Clinical pharmacist (ISCO 2262) | Records officer (ISCO 4132) |
References
- Centers for Disease Control and Prevention (USA) (2022). Clinical Practice Guideline for Prescribing Opioids for Pain. Used for: monitoring and recording of opioid use (10.4). https://news.gmj.ge/guideline/clinical-practice-guideline-for-prescribing-opioids-for-pain-united-states-2022/
- World Health Organization (2025). WHO Guideline on Balanced National Controlled Medicines Policies to Ensure Medical Access and Safety. Used for: controlled medicines registers and counts (10.4). https://news.gmj.ge/guideline/who-balanced-national-controlled-medicines-policies/
10.5
Patients and Families Are Informed About Their Pain Plan
Humanitarian settings: MinimumTransition and fragile: MediumStandard: Must
The patient and family are told what the pain plan is, what to expect, what side effects to watch for and whom to call. The information is given in a language they understand and recorded.
Rating: Minimum in humanitarian settings; Medium in transition and fragile settings; Must in standard settings.
Not assessed (N/A) for: fitness and wellness.
Why it matters. A patient who knows the plan takes medicines correctly, reports problems early and is less afraid of pain. Families who understand the plan can support the patient safely at home.
Questions the surveyor asks
- Is the patient told about the plan in plain language? Dose, timing, side effects and the next review.
- Is the family or carer included where the patient agrees? Carers often give the medicines at home.
- Is the information recorded? A record shows what was told and when.
How the surveyor verifies this criterion
Sample. Twenty patient records from the last 3 months, and the family information leaflets used.
1. Patient is told about the plan
Method. Check each sampled record for an information entry.
Evidence to show. Family and carer support and information (HSP-SOP-001).
Pass when. Each sampled record shows the plan was explained.
2. Family and carer are included
Method. Check the record for a family or carer entry where the patient agreed.
Evidence to show. Record of goals, values and wishes (HSP-FRM-002).
Pass when. The family or carer is included in each sampled case where the patient agreed.
3. Information is recorded
Method. Check that the information given is recorded with date and staff name.
Evidence to show. Family and carer support and information (HSP-SOP-001).
Pass when. Each sampled record has a dated information entry.
Immediate fail (any one means the criterion is not met)
- Patients are not told about their pain plan at all.
Staff, training and documents
Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.
Good practice. Patients and families told about the plan in plain language, with the information recorded.
Partial because. Patients are told, but the information is not recorded or not in a language they understand.
Staff responsible
| Role | Why it applies | Level | Training | Documents |
|---|---|---|---|---|
| Registered nurse ISCO 2221 ASF proposal |
Explains the pain plan and gives the patient and family written information. | Humanitarian: Essential Transition: Essential Standard: Essential |
Patient Identification, Informed Consent and Patient Rights (T-07) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
HSP-SOP-001 HSP-FRM-002 |
| Prescriber (doctor) ISCO 2212 ASF proposal |
Discusses the plan, its benefits and its risks with the patient. | Humanitarian: Essential Transition: Essential Standard: Essential |
Patient Identification, Informed Consent and Patient Rights (T-07) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
— |
| Clinical pharmacist ISCO 2262 ASF proposal |
Explains each medicine and its possible effects. | Humanitarian: Essential Transition: Essential Standard: Essential |
Patient Identification, Informed Consent and Patient Rights (T-07) Evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or a training certificate in the staff file |
— |
E-learning: who must take each course.
| E-learning course | Who must take | Who is recommended |
|---|---|---|
| Patient Identification, Informed Consent and Patient Rights (T-07) GMJ Academy: English · Georgian |
Registered nurse; Prescriber (doctor) | Clinical pharmacist |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| HSP-SOP-001 · Family and carer support and information Procedure (SOP) · To keep families informed and supported in their role. |
Registered nurse (ISCO 2221) | Quality lead (ISCO 1342) | N/A | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
| HSP-FRM-002 · Record of goals, values and wishes Form (record) · Records the patient’s goals, values and wishes, including advance directives, and when they were reviewed. |
Registered nurse (ISCO 2221) | N/A | Registered nurse (ISCO 2221) | Quality lead (ISCO 1342) | Records officer (ISCO 4132) |
References
- World Health Organization (2021). Quality health services and palliative care: practical approaches and resources to support policy, strategy and practice. Used for: informing and supporting patients and families (10.5). https://news.gmj.ge/guideline/quality-health-services-and-palliative-care-practical-approaches-and-resources-to-support-policy-strategy-and-practice/
- World Health Organization (2019). Integrating palliative care and symptom relief into primary health care. Used for: family and carer support (10.5). https://news.gmj.ge/guideline/integrating-palliative-care-and-symptom-relief-into-primary-health-care/
Role details: reporting, supervision and training
Each role links to its own terms of reference, which holds the full reporting line, supervision, training and competency record.
| Role | Reports to | Supervises | Core training |
|---|---|---|---|
| Prescriber (doctor) ISCO 2212 | The head of department (per specialty). | Resident physicians and house officers. | Prescribing & Controlled Substance Management (TM-05) End-of-Life & Palliative Care (LTC-06) High-Alert Medication Safety (PS-03) Patient Identification, Informed Consent and Patient Rights (T-07) |
| Clinical pharmacist ISCO 2262 | The chief pharmacist. | Pharmacy technicians and pharmacy assistants. | Prescribing & Controlled Substance Management (TM-05) End-of-Life & Palliative Care (LTC-06) Medication Management & Family Coordination (HC-04) Patient Identification, Informed Consent and Patient Rights (T-07) |
| Registered nurse ISCO 2221 | The head nurse. | Nursing associates and health care assistants. | The Medication-Use Process (PS-10) End-of-Life & Palliative Care (LTC-06) High-Alert Medication Safety (PS-03) Patient Identification, Informed Consent and Patient Rights (T-07) |
Who is responsible for Standard 10
Each criterion below names the positions responsible for it.
| Criterion | Positions responsible or involved | |
|---|---|---|
| 10.1 | Opioid Prescribing Is Deliberately Stewarded | Prescriber (doctor) · Clinical pharmacist · Registered nurse |
| 10.2 | Pain Is Formally Assessed and Reassessed, Not Just Asked About Once | Registered nurse · Prescriber (doctor) · Clinical pharmacist |
| 10.3 | Pain and Symptoms Are Assessed and Controlled | Registered nurse · Prescriber (doctor) · Clinical pharmacist |
| 10.4 | Opioids and Controlled Medicines Are Managed Safely | Clinical pharmacist · Prescriber (doctor) · Registered nurse |
| 10.5 | Patients and Families Are Informed About Their Pain Plan | Registered nurse · Prescriber (doctor) · Clinical pharmacist |
Quality oversight
The quality chain keeps this standard under review, from the governing body down to the teams that run each process.
Questions and answers
The criterion text is the authority. These answers summarise it.
Who does Standard 10 apply to?
Every facility that treats pain, or that prescribes, stores or gives opioids or other controlled medicines. The table at the top of this page shows each criterion by facility type. Criteria 10.1 and 10.4 are N/A for telemedicine, fitness and wellness, and aesthetic and procedure clinics. Criteria 10.2, 10.3 and 10.5 are N/A for fitness and wellness only. Each criterion is marked where it applies.
What is an immediate fail?
An immediate fail is one finding that means a criterion is not met, even if the rest of it is in place. For example, a patient in pain with no pain plan and no out-of-hours route fails criterion 10.3 outright, and a controlled medicine that is missing and not reported fails criterion 10.4. Each criterion on this page states its own immediate fail under “Immediate fail”. Read these before the survey, because they are the points on which the outcome is decided most quickly.
Which documents do I submit?
The documents are the policies, procedures, forms and records listed under each criterion in the “Evidence and documents” table. Where a criterion lists no document, the facility keeps its own record. Policies and procedures are signed documents that show the version, date, owner and approver. You may use your own document if it meets the same check and is clearly the same record.
Are the ratings the same in every setting?
No. Two criteria protect life and are Must in every setting: pain assessment and reassessment (10.2) and controlled medicines (10.4). The other three criteria are Medium or Minimum in humanitarian and transition settings, and Must in standard settings. Each criterion shows its rating for each of the three settings.
Why is opioid stewardship Medium in humanitarian settings?
In a humanitarian setting a facility may have few prescribers, a short list of medicines and little choice of non-opioid treatment. The criterion is still required: the facility must have a written approach, a named person and recorded reviews, adapted to what it can realistically do. In standard settings every element is Must.
What must a pain assessment include?
An agreed pain tool, recorded in every patient record, used on admission and reassessed at a set interval and after any change in the patient’s condition or treatment. The result must change the plan when it changes. Where a patient cannot describe their pain, the facility states the tool it uses instead and records it.
How often must pain be reassessed?
At the interval the facility sets in its pain policy, and after any change in condition or treatment. The surveyor checks that pain was reassessed at the set interval in at least 18 of the 20 sampled records. A reassessment that is not recorded does not count.
Do patients have to sign a pain plan?
No. Criterion 10.5 requires that the patient and family are told what the plan is, what to expect, which side effects to watch for and whom to call. The facility records that the information was given and in what language. A signature is optional.
What must a symptom plan include?
A written plan for each patient in pain, with a breakthrough dose and a call point for when pain is not controlled. The plan must be readable by any clinician on shift, not only the doctor who wrote it. The surveyor checks ten patient plans from the last 3 months.
Do we need out-of-hours advice for pain?
Yes. Criterion 10.3 requires a named route for advice out of hours, and each advice call is logged. The route must be known to the ward or home team and to the patient or carer where they are cared for at home.
How do we keep controlled medicines safe?
Controlled medicines are stored securely, recorded in a register, and counted at each handover with two signatures. The register must be complete and the balance must match the stock. Diversion checks are part of the routine, and the surveyor checks the register and count sheets for the last 3 months.
What happens if a controlled medicine is missing?
It must be recorded, reported and investigated, with the outcome written down. A controlled medicine that is missing and not reported fails criterion 10.4 outright. The facility must show each discrepancy, its investigation and its result.
What if a patient cannot describe their pain?
The facility uses an observational or behavioural tool that it has agreed, states it in the policy, and records it in each assessment. The tool must be used the same way by all staff. Where a patient can self-report again, the facility returns to the usual tool.
How does this standard differ from Standard 8?
Standard 8 covers medicines safety in general. Standard 10 covers pain, its assessment and its control, and the particular risks of opioids and other controlled medicines: prescribing, storage, counting and disposal. Some records, such as the prescription review and the controlled drugs register, may serve both standards where they meet the same check.
Do we have to use ISCO-08 codes?
The staff tables give each occupation its ISCO-08 code, so that roles can be compared between facilities and countries. You are not required to change your job titles. What matters is that each role named in the standard can be matched to the person who does that job and to the training they have had. If your titles differ, record the match in your staff file.
Which training do staff need?
The e-learning table under each criterion shows who must take each course and who is recommended. Prescribers and pharmacists take Prescribing & Controlled Substance Management for criteria 10.1 and 10.4, and nurses take High-Alert Medication Safety for criterion 10.4. Nurses and doctors take End-of-Life & Palliative Care for criteria 10.2 and 10.3. Each course name opens its course page in the GMJ Academy. Where a course is published in English only, the English page is linked. Where no GMJ Academy course exists, the hospital provides the training itself and records it in the staff file.
What will the surveyor see on the day?
The surveyor reviews the records for each criterion: the opioid policy and prescription reviews, the pain assessment records, the symptom plans and the out-of-hours advice log, the controlled drugs register and count sheets, and the patient information given. The surveyor may talk to nurses and doctors about how they reassess pain and how they count controlled medicines.
What if we do not have the written protocol yet?
A criterion cannot be met on the basis of an unwritten arrangement, because the assessor needs something to check against. If a protocol does not yet exist, write one before the survey, using the reference draft or your own version, and make sure it is signed, dated and in use. Staff must be able to explain it in practice.
Do we have to use your forms and policies?
No. Every policy, procedure, form and course on this page is a reference draft to help you meet the criterion. You can adapt it, write your own, or upload your own documents. What the assessor checks is that the standard is met and that you can show how. If you use your own document, make sure it covers the same content as the reference, and that it is current, signed and dated.
What do the colours mean?
Red means Must: the criterion is required in every setting, and criteria that protect life, such as pain assessment and controlled medicines, are always red. Yellow means Medium: the criterion is required, adapted to what a transition setting can realistically do. Green means Minimum: the lowest acceptable level in a humanitarian setting, where resources are very limited. In standard settings every criterion is Must. Each criterion shows its rating for each of the three settings.
Where can I get the full text?
The full text of each criterion, with its rating, why it matters, the assessor checks, the immediate-fail rule and the documents, is on this page. A PDF with the same criteria, for printing and for assessors, is linked from the download box at the top of this page. If the questions and answers ever differ from the criteria, the criterion text is the authority.
Who can I ask about this standard?
For questions about this standard, contact Accréditation Sans Frontières through the Contact page of this website. Please give the standard number and the criterion (for example 10.3) so that your question can be answered against the right text.
E-learning by standard
These are the GMJ Academy courses named in the criteria of this standard. Each course name opens the course page in the academy. Where a course is published in English and in Georgian, both versions are linked. Evidence of completion is a verified micro-credential in the GMJ Academy micro-credential portfolio, or a training certificate in the staff file.
| E-learning course | Who must take | Who is recommended | Criteria |
|---|---|---|---|
| Prescribing & Controlled Substance Management (TM-05) GMJ Academy: English · Georgian |
Prescriber (doctor); Clinical pharmacist | Registered nurse | 10.1, 10.4 |
| The Medication-Use Process (PS-10) GMJ Academy: English · Georgian |
Clinical pharmacist; Registered nurse | Prescriber (doctor) | 10.1 |
| End-of-Life & Palliative Care (LTC-06) GMJ Academy: English · Georgian |
Registered nurse; Prescriber (doctor) | Clinical pharmacist | 10.2, 10.3 |
| Medication Management & Family Coordination (HC-04) GMJ Academy: English · Georgian |
Registered nurse | Clinical pharmacist | 10.3 |
| High-Alert Medication Safety (PS-03) GMJ Academy: English · Georgian |
Registered nurse; Clinical pharmacist | Prescriber (doctor) | 10.4 |
| Addiction Medicine & Controlled Substances (AMB-21, Georgian version only) GMJ Academy: Georgian |
Prescriber (doctor) | Registered nurse | 10.4 |
| Patient Identification, Informed Consent and Patient Rights (T-07) GMJ Academy: English · Georgian |
Registered nurse; Prescriber (doctor) | Clinical pharmacist | 10.5 |
Back to ASF Health Standards V11 · Standards Map · E-learning by standard · References
Related courses in the GMJ Academy
These courses cover the same subjects in more depth or for a specific type of facility. They are optional. They are not required by the criteria.
| Course | Subject |
|---|---|
| Chronic Disease Management in Primary Care (PHC-03) GMJ Academy: https://academy.gmj.ge/course-search/asf-phc-03-en/ |
Chronic disease management in primary care |
| Clinical & Medical Care in Long-Term Care (LTC-04) GMJ Academy: https://academy.gmj.ge/course-search/asf-ltc-04-en/ |
Clinical and medical care in long-term care |
| Care Plan Development & Ongoing Supervision (HC-06) GMJ Academy: https://academy.gmj.ge/course-search/asf-hc-06-en/ |
Care plan development and ongoing supervision |
| Continuous Monitoring in Critical Care () GMJ Academy: https://academy.gmj.ge/course-search/asf-crt-01-en/ |
Continuous monitoring in critical care |
References and guidelines for this standard
The guidelines and references cited in the criteria above are listed here. Each link opens the full text.
- World Health Organization (2025). WHO Guideline on Balanced National Controlled Medicines Policies to Ensure Medical Access and Safety. Used for: safe prescribing and control of opioids (10.1). https://news.gmj.ge/guideline/who-balanced-national-controlled-medicines-policies/
- Centers for Disease Control and Prevention (USA) (2022). Clinical Practice Guideline for Prescribing Opioids for Pain. Used for: starting, reviewing and stopping opioid prescriptions (10.1). https://news.gmj.ge/guideline/clinical-practice-guideline-for-prescribing-opioids-for-pain-united-states-2022/
- World Health Organization (2019). Guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents. Used for: pain assessment and reassessment (10.2). https://news.gmj.ge/guideline/guidelines-for-the-pharmacological-and-radiotherapeutic-management-of-cancer-pain-in-adults-and-adolescents/
- World Health Organization (2023). Guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. Used for: pain assessment in non-cancer pain (10.2). https://news.gmj.ge/guideline/guideline-for-non-surgical-management-of-chronic-primary-low-back-pain-in-adults-in-primary-and-community-care-settings/
- World Health Organization (2019). Integrating palliative care and symptom relief into primary health care. Used for: symptom assessment and control (10.3). https://news.gmj.ge/guideline/integrating-palliative-care-and-symptom-relief-into-primary-health-care/
- World Health Organization (2021). Quality health services and palliative care: practical approaches and resources to support policy, strategy and practice. Used for: symptom control in serious illness (10.3). https://news.gmj.ge/guideline/quality-health-services-and-palliative-care-practical-approaches-and-resources-to-support-policy-strategy-and-practice/