Standards › ASF Health Standards v10 › Standard 58
Standard 58
Inpatient Ward Care
Inpatient ward care: admission assessment and daily review, medicines reconciled and checked before each dose, deterioration recognised and escalated early, falls, pressure injuries and infections prevented, and discharge planned with a safe handover..
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.
58.1Every Inpatient Has an Admission Assessment and a Daily ReviewHumanitarian settings: MustTransition and fragile: MustStandard: Must
Each inpatient has a documented admission assessment covering falls, pressure injury, nutrition and venous thromboembolism risk, and the plan is reviewed by a clinician every day.
Why it matters.
How the surveyor verifies this criterion
Sample. Review the admission assessments and daily reviews for every inpatient admitted in the last 3 months, with a sample of daily reviews.
1. The plan is reviewed by a clinician every day.
Method. Check each sampled inpatient for a daily review entry for each day of stay.
Evidence to show. Admission assessment and daily review on the ward (WRD-SOP-001).
Pass when. Every sampled inpatient has a daily review recorded for every day of stay.
2. Changes in risk are acted on in the plan.
Method. Check each recorded risk change for the plan update.
Evidence to show. Ward admission and daily review record (WRD-FRM-001).
Pass when. Every recorded risk change has a plan update.
Immediate fail (any one means the criterion is not met). A frail patient is admitted and no falls or pressure assessment is done, and falls on day two with a hip fracture.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Manager (ISCO 1342) | Maintains the Ward admission and daily review record (WRD-FRM-001); admission and daily review procedure | Must |
| Nurse (ISCO 2221) | Completes the Ward admission and daily review record | Must |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| WRD-SOP-001 · Admission assessment and daily review on the ward | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
| WRD-FRM-001 · Ward admission and daily review record | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Safety & Emergency Preparedness (H-05) | Manager; Nurse |
References
- NICE (n.d.). Acutely ill adults in hospital: recognising and responding to deterioration. Used for: Daily review and deterioration https://news.gmj.ge/guideline/acutely-ill-adults-in-hospital-recognising-and-responding-to-deterioration/
58.2Medicines Are Reconciled and Given Safely on the WardHumanitarian settings: MustTransition and fragile: MustStandard: Must
Medicines are reconciled at admission, transfer and discharge. High-alert medicines are checked before each dose, and every omitted or refused dose is recorded with the reason.
Why it matters.
How the surveyor verifies this criterion
Sample. Review the medicines charts and omission records for a sample of inpatients in the last 3 months, including the high-alert medicines.
1. High-alert medicines are checked before each dose.
Method. Observe the check for each sampled high-alert dose, and review the chart.
Evidence to show. Ward medicine administration checks (WRD-SOP-002).
Pass when. Every sampled high-alert dose has the check recorded.
2. Each omitted or refused dose is recorded with the reason.
Method. Check the omission register against the charts for the sample period.
Evidence to show. Medicine administration and omission register (WRD-REG-001).
Pass when. Every omitted or refused dose in the sample has a recorded reason.
Immediate fail (any one means the criterion is not met). A high-alert insulin dose is given twice in one shift because the chart was not checked, and the patient becomes hypoglycaemic.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Manager (ISCO 1342) | Maintains the High-alert medicines (HOS-SOP-006, existing, reused); ward medicine administration checks | Must |
| Secretary (ISCO 3344) | Keeps the Medicine administration and omission register | Must |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| WRD-SOP-002 · Ward medicine administration checks | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
| WRD-REG-001 · Medicine administration and omission register | Secretary (ISCO 3344) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Medication Safety: Operating SOP-MED-01 End to End (T-08) | Manager; Nurse |
References
- WHO (2020). Medication safety in transitions of care. Used for: Medicines reconciliation at transfers https://news.gmj.ge/guideline/medication-safety-in-transitions-of-care/
- WHO (2017). Medication Without Harm – Global Patient Safety Challenge on Medication Safety. Used for: Medicines safety on the ward https://news.gmj.ge/guideline/medication-without-harm-global-patient-safety-challenge-on-medication-safety/
58.3Deterioration Is Recognised and Escalated Without DelayHumanitarian settings: MinimumTransition and fragile: MustStandard: Must
Vital signs are recorded at the set frequency, scored with an early warning tool, and escalated to a senior clinician when the score or a clinical concern meets the escalation threshold.
Why it matters.
How the surveyor verifies this criterion
Sample. Review the vital signs charts and early warning score records for every patient who was escalated in the last 3 months, plus a random sample of other inpatients.
Immediate fail (any one means the criterion is not met). A patient with a high early warning score is not escalated for three hours, and is found in septic shock.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Manager (ISCO 1342) | Checks the criterion at each review | Must |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| HOS-SOP-002 · Vital signs and deterioration response | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
| HOS-FRM-002 · Observation and early warning chart | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Handover & Communication for ASF Accreditation (MT-04) | Manager; Nurse |
References
- NICE (n.d.). Acutely ill adults in hospital: recognising and responding to deterioration. Used for: Recognition and escalation of deterioration https://news.gmj.ge/guideline/acutely-ill-adults-in-hospital-recognising-and-responding-to-deterioration/
- WHO (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Used for: Escalation of deterioration https://news.gmj.ge/guideline/global-patient-safety-action-plan-2021-2030-towards-eliminating-avoidable-harm-in-health-care/
58.4Falls, Pressure Injuries and Infections Are Prevented on the WardHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must
Each patient at risk of falls or pressure injury has a prevention plan in use. Hand hygiene is practised at the point of care, and healthcare-associated infections are recorded and reviewed.
Why it matters.
How the surveyor verifies this criterion
Sample. Review falls, pressure injury and infection records for the ward over the last 6 months, with a sample of at-risk inpatients.
Immediate fail (any one means the criterion is not met). A patient with a known fall risk falls at night with no bed alarm in place, and the event is not recorded.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Manager (ISCO 1342) | Checks the criterion at each review | Medium |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| PSF-SOP-001 · Falls Risk Assessment and Prevention | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
| CLN-FRM-006 · Pressure injury risk and prevention record | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Slip, Trip & Fall Prevention (FALL-01) | Manager; Nurse |
References
- NICE (n.d.). Falls: assessment and prevention in older people and in people 50 and over at higher risk. Used for: Falls prevention on the ward https://news.gmj.ge/guideline/falls-assessment-and-prevention-in-older-people-and-in-people-50-and-over-at-higher-risk/
- WHO (2021). Step Safely: Strategies for Preventing and Managing Falls Across the Life-Course. Used for: Falls prevention https://news.gmj.ge/guideline/step-safely-strategies-for-preventing-and-managing-falls-across-the-life-course/
- NICE (n.d.). Pressure ulcers: prevention and management. Used for: Pressure injury prevention https://news.gmj.ge/guideline/pressure-ulcers-prevention-and-management/
- WHO (2020). Minimum requirements for infection prevention and control programmes. Used for: Infection prevention on the ward https://news.gmj.ge/guideline/minimum-requirements-for-infection-prevention-and-control-programmes/
58.5Discharge Is Planned and Handed Over SafelyHumanitarian settings: MinimumTransition and fragile: MediumStandard: Must
Each discharge is planned before the day of discharge, with reconciled medicines, written aftercare and a booked follow-up, and a structured handover is sent to the next clinician.
Why it matters.
How the surveyor verifies this criterion
Sample. Review the discharge records and handover letters for every discharge in the last 3 months, including discharges with follow-up.
Immediate fail (any one means the criterion is not met). A patient is discharged on a changed anticoagulant dose with no reconciliation, and bleeds at home.
Staff responsible
| Role | Responsibility | Level |
|---|---|---|
| Manager (ISCO 1342) | Checks the criterion at each review | Medium |
Documents: who does each step
| Document | Writes | Approves | Fills in | Checks and signs | Files and uploads |
|---|---|---|---|---|---|
| HOS-FRM-004 · Handover record | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
| SHO-SOP-001 · Safe handover procedure: when and how clinicians hand over care | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) |
| AFT-FRM-001 · Follow-up booking before discharge | Manager (ISCO 1342) | Chief executive (ISCO 1120) | Secretary (ISCO 3344) | Manager (ISCO 1342) | Secretary (ISCO 3344) |
E-learning: who must take each course
| Course | Who must take it |
|---|---|
| Aftercare & Follow-up: Standards for Safe Discharge (H-06) | Manager; Nurse |
References
- WHO (2020). Medication safety in transitions of care. Used for: Discharge medicines and handover https://news.gmj.ge/guideline/medication-safety-in-transitions-of-care/
Who is responsible for Standard 58
Each criterion names the positions responsible for it. Every position links to its own terms of reference.
| Criterion | Responsible | Supports |
|---|---|---|
| 58.1 Every Inpatient Has an Admission Assessment and a Daily Review | Consultant physician (internal medicine) Registered nurse |
Head nurse / ward manager |
| 58.2 Medicines Are Reconciled and Given Safely on the Ward | Clinical pharmacist | Registered nurse |
| 58.3 Deterioration Is Recognised and Escalated Without Delay | Registered nurse Consultant physician (internal medicine) |
Head nurse / ward manager |
| 58.4 Falls, Pressure Injuries and Infections Are Prevented on the Ward | Head nurse / ward manager Registered nurse |
IPC nurse |
| 58.5 Discharge Is Planned and Handed Over Safely | Registered nurse Head nurse / ward manager |
Social worker |
Role details: reporting, supervision and training
Training shown is the general recommendation. Role-specific training is set in the next improvement round.
| Role | Reports to | Supervises | Recommended training |
|---|---|---|---|
| IPC nurse | Infection prevention and control (IPC) lead | None | Facility induction; safeguarding adults (general recommendation) |
| Consultant physician (internal medicine) | Head of department (per specialty) | Resident physician / house officer | Facility induction; safeguarding adults (general recommendation) |
| Head nurse / ward manager | Director of nursing | Nurse specialist, Registered nurse, Nursing associate, Health care assistant / nursing aide | Facility induction; safeguarding adults (general recommendation) |
| Registered nurse | Head nurse / ward manager | Nursing associate, Health care assistant / nursing aide | Facility induction; safeguarding adults (general recommendation) |
| Social worker | Patient services manager | None | Facility induction; safeguarding adults (general recommendation) |
| Clinical pharmacist | Chief pharmacist | None | Facility induction; safeguarding adults (general recommendation) |
Questions and answers
The criterion text is the authority. These answers summarise it.
Who does Standard 65 apply to?
Hospital wards that care for inpatients, including medical, surgical and general ward teams.
What do the colours mean for this standard?
Red (Must) is required. Green (Medium) is recommended. Yellow (Minimum) is the lowest acceptable level in humanitarian settings. Standard setting is Must on every criterion.
What is needed on admission?
Under 58.1 each inpatient has a documented admission assessment covering falls, pressure injury, nutrition and VTE risk, and a clinician reviews the plan every day.
Are medicines checked on the ward?
Yes. Under 58.2 medicines are reconciled at admission, transfer and discharge, high-alert medicines are checked before each dose, and every omitted dose is recorded with its reason.
How is deterioration handled?
Under 58.3 vital signs are recorded at the set frequency, scored with an early warning tool, and escalated to a senior clinician without delay.
How are falls, pressure injuries and infections prevented?
Under 58.4 patients at risk have a prevention plan in use, hand hygiene is practised at the point of care, and healthcare-associated infections are recorded.
How is discharge handled?
Under 58.5 discharge is planned before the day of discharge, with reconciled medicines, written aftercare, a booked follow-up and a structured handover to the next clinician.
Guidelines for this standard
4 guideline(s) are held in the GMJ Guidelines Library and listed here. Each link opens the full guideline on news.gmj.ge. The complete library, grouped by standard, is at Guidelines.
- Transition between inpatient hospital settings and community or care home settings for adults with social care needs (NG27) (National Institute for Health and Care Excellence)
- Medication safety in transitions of care (WHO)
- Minimum requirements for infection prevention and control programmes (World Health Organization)
- Considerations on Thrombotic Events Following Administration of the Oxford-AstraZeneca COVID-19 Vaccine in Europe (Pan American Health Organization)
Also relevant to this standard:
- National Early Warning Score (NEWS2) (NHS England)
- Acutely Ill Adults in Hospital: Recognising and Responding to Deterioration (CG50) (NICE)
- National Early Warning Score (NEWS2) (Royal College of Physicians)
- Acutely ill adults in hospital: recognising and responding to deterioration (National Institute for Health and Care Excellence (UK))
- Pressure ulcers: prevention and management (National Institute for Health and Care Excellence (UK))
- Medication Without Harm – Global Patient Safety Challenge on Medication Safety (World Health Organization)
- Step Safely: Strategies for Preventing and Managing Falls Across the Life-Course (World Health Organization)
- Falls: assessment and prevention in older people and in people 50 and over at higher risk (National Institute for Health and Care Excellence (UK))