Standard operating procedure

Baseline & Ongoing Investigations SOP

Which investigations [Organisation Name] requests, when and why, and how every blood test, imaging and bone density result is tracked, received, reviewed, acted on and communicated so that no result goes missing

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What's inside

This standard operating procedure is fully drafted and structured, ready to brand and complete for your service. It covers:

  • 1. Purpose
  • 2. Scope
  • 3. Definitions and abbreviations
  • 4. Responsibilities
  • 5. Equipment, systems and information required
  • 6. What is and is not requested routinely
  • 7. Requesting investigations
  • 8. Receiving, matching and reviewing results
  • 9. Acting on and communicating results
  • 10. Critical results, out-of-hours reporting and absent clinicians
  • 11. Patients who cannot be contacted
  • 12. Imaging, ultrasound and DXA failsafe
  • 13. Results obtained elsewhere
  • 14. Results failsafe log
  • 15. Safety netting and patient information
  • 16. Records
  • 17. Training and competence
  • 18. Monitoring and audit
  • 19. Related documents
  • 20. Review and version control
  • 21. Disclaimer

CQC fundamental standard

Regulation 9 (Person-centred care)
This document is written to evidence that standard. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Legislation & standards it maps to

  • National Institute for Health and Care Excellence (NICE) guideline NG23, Menopause: identification and management (as last updated).
  • NICE guideline NG12, Suspected cancer: recognition and referral (as last updated).
  • British Menopause Society Tool for Clinicians: Testosterone replacement in menopause (May 2026), and the 2024 joint guideline on the management of unscheduled bleeding on hormone replacement therapy led by the British Menopause Society.
  • General Medical Council (GMC), Good practice in proposing, prescribing, providing and managing medicines and devices, including the sections on remote prescribing and on medicines requiring additional safeguards; GMC, Remote consultations guidance and decision flowchart; GMC, Confidentiality: good practice in handling patient information.
  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in particular Regulation 9 (Person-centred care), Regulation 11 (Need for consent), Regulation 12 (Safe care and treatment), Regulation 17 (Good governance) and Regulation 20 (Duty of candour).
  • Care Quality Commission (CQC) assessment framework: the five key questions (safe, effective, caring, responsive and well-led) and the quality statements of the single assessment framework, and the sector-specific framework for primary care and community services when it replaces them.
  • Ionising Radiation (Medical Exposure) Regulations 2017, for referrals for dual-energy X-ray absorptiometry.
  • UK General Data Protection Regulation and Data Protection Act 2018; Records Management Code of Practice (2023).

Who it applies to

All prescribing clinicians (who may be registered with the General Medical Council, the Nursing and Midwifery Council or the General Pharmaceutical Council), the [Clinical Lead], the Registered Manager, results and administrative staff, and self-employed and locum clinicians at [Organisation Name], whether care is delivered in person or remotely

Glossary

Plain-English explanations of the technical terms and legislation used in this document.

Abnormal result
A test result that needs something to be done, such as a treatment change, repeat test or referral.
British Menopause Society (BMS)
The UK specialist society for health professionals working in menopause care, which publishes guidance and Tools for Clinicians.
Care Quality Commission (CQC)
The independent regulator of health and social care services in England.
Closure
The point at which a result has been reviewed, acted on and communicated, so its tracking entry can be closed.
Critical result
A result showing an immediate risk to health that must be acted on the same day.
Data Protection Act 2018
The UK law, alongside the UK GDPR, governing how personal information must be handled.
Dual-energy X-ray absorptiometry (DXA)
A low-dose X-ray scan that measures bone density to help assess the risk of fractures.
Duty (buddy) clinician
A named clinician who deals with a colleague's results while they are away.
Duty of candour
The legal duty to be open and honest with patients when something goes wrong that causes, or could cause, significant harm (Regulation 20).
Endometrial thickness
The thickness of the womb lining measured on ultrasound, used to decide whether bleeding needs further investigation.
Equality Act 2010
The law protecting people from discrimination, including on the grounds of sex and gender reassignment.
Failsafe
A system that catches errors or omissions before they cause harm, here ensuring no result is missed.
Ferritin
A blood test showing how much iron the body has stored.
Follicle-stimulating hormone (FSH)
A hormone that rises around the menopause; its level varies a lot during perimenopause, so it is only useful in certain patients.
Free androgen index (FAI)
A calculation from testosterone and SHBG levels that the BMS advises is not a reliable guide to testosterone treatment.
Full blood count
A blood test measuring red cells, white cells and platelets, used for example to check for anaemia.
General Medical Council (GMC)
The regulator of doctors in the UK.
General Pharmaceutical Council (GPhC)
The regulator of pharmacists and pharmacy technicians in Great Britain.
General practitioner (GP)
The patient's family doctor.
Glycated haemoglobin (HbA1c)
A blood test showing average blood sugar over the previous 2 to 3 months.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The regulations setting the fundamental standards that providers of regulated care must meet, enforced by the CQC.
Hormone replacement therapy (HRT)
Medicines that replace oestrogen, usually with a progestogen, to relieve menopausal symptoms.
Ionising Radiation (Medical Exposure) Regulations 2017
The law protecting patients having X-ray based tests, including rules on who may refer and what information a referral must include.
ISO 15189
The international standard for quality and competence in medical laboratories, published by ISO, the international standards body.
Liquid chromatography-tandem mass spectrometry (LC-MS/MS)
A precise laboratory method for measuring hormones such as testosterone.
Medicines and Healthcare products Regulatory Agency (MHRA)
The UK regulator of medicines and medical devices.
National Institute for Health and Care Excellence (NICE)
The body that publishes national evidence-based guidance on health and care in England.
NICE guideline NG12
Suspected cancer: recognition and referral - national guidance on when to refer people with symptoms that could be cancer.
NICE guideline NG23
Menopause: identification and management - national guidance on diagnosing and treating menopause.
Nursing and Midwifery Council (NMC)
The regulator of nurses and midwives in the UK.
Oestradiol
The main natural oestrogen, and the form used in most HRT.
Records Management Code of Practice (2023)
National guidance on how long health and care records should be kept and how they should be managed.
Reference range
The range of results the laboratory considers normal for the test.
Safety netting
Telling patients what to look out for and what to do if things change or they do not hear back.
Sex hormone-binding globulin (SHBG)
A protein in the blood that carries sex hormones and affects how much is available to the body.
Standard Operating Procedure (SOP)
A written, step-by-step instruction describing how a task is carried out consistently and safely.
Suspected cancer pathway referral
An urgent referral for people whose symptoms could be cancer, so they are assessed quickly.
Total testosterone
The total amount of testosterone in the blood, the measure used to monitor testosterone treatment.
Transvaginal ultrasound
An internal ultrasound scan that gives a clear view of the womb lining and ovaries.
Turnaround time
How long a laboratory or scan provider takes to report a result.
UK General Data Protection Regulation (UK GDPR)
The UK's main data protection law governing how personal information is collected and used.
United Kingdom Accreditation Service (UKAS)
The national body that checks and accredits laboratories as competent.
Welfare check
A visit, usually by the police, to check that a person who cannot be contacted is safe.

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Related documents

PolicyWomen's Health Scope of Service Policy£44.99
PolicyMenopause Assessment & Diagnosis Policy£44.99
PolicyHRT Prescribing Policy£44.99
PolicyTestosterone Prescribing in Women Policy£44.99

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