A Protocolo Operacional Padrão (POP) is the Brazilian term many teams use for a Standard Operating Procedure (SOP). If you work in healthcare (or any high-stakes service), POPs keep work consistent, safer, and easier to train.
They also prevent that classic workplace moment: “Wait… who taught you that way?”
This guide explains what a POP is, how to create one, and how to implement it—with practical examples for nursing, dentistry, psychology, physiotherapy, sterilisation/CME, and even SAMU 192 operations.
What is a Protocolo Operacional Padrão (POP)?
A POP (protocolo operacional padrão/pop protocolo operacional padrão) is a written, controlled document that describes exactly how to perform a task in a consistent way.
A good POP answers:
- Who does the task
- When they do it
- How they do it (step-by-step)
- What to do if something goes wrong
- Where to document the work
“Protocol”: what is it (protocolo o que é) vs. POP?
People often mix up “protocol” and “procedure.” In many organisations:
- A protocol (protocolo) guides clinical or decision logic (e.g., triage criteria, treatment pathways, escalation rules).
- A procedimento operacional padrão / procedimento operacional describes how to execute a task operationally (e.g., how to prepare a medication tray, how to label sterilised packs, how to register an event in the system).
That’s the key diferença entre protocolo e procedimento operacional padrão:
- Protocol = what/when to decide
- POP/SOP = how to do it correctly, every time
If you want a simple mental test:
If the document reads like “If X, then do Y,” you’re closer to a protocol.
If it reads like “Step 1, Step 2, Step 3,” you’re closer to a POP.
Why POPs matter (especially in healthcare)
POPs support quality and safety because they reduce variation. In regulated environments, they also support compliance.
For example:
- The WHO Guidelines on Hand Hygiene in Health Care emphasize standardized processes, staff training, and monitoring to improve compliance and reduce infection risk. (World Health Organisation, 2009: https://www.who.int/publications/i/item/9789241597906)
- In sterilisation and reprocessing, the CDC Guideline for Disinfection and Sterilisation in Healthcare Facilities explains why facilities must follow validated, consistent methods for cleaning and sterilising devices. (CDC: https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/index.html)
In Brazil, health services also align with ANVISA requirements for processing medical products—especially in CME (Central Material and Sterilisation). ANVISA’s RDC nº 15/2012 sets good practices for the processing of health products and requires organised, standardised workflows. (ANVISA RDC 15/2012: https://bvsms.saude.gov.br/bvs/saudelegis/anvisa/2012/rdc0015_15_03_2012.html)
How to make a Protocolo Operacional Padrão (como fazer um protocolo operacional padrão)
You don’t need a 40-page document. You need a POP that people actually follow.
Step 1: Choose one process and define the scope
Start with a process that causes real pain:
- Rework
- Incidents
- Training confusion
- Audit findings
- Delays or bottlenecks
Define scope in one sentence, such as:
- “This POP covers packaging and labelling of sterilised sets in the CME.”
- “This POP covers patient check-in and documentation for outpatient physiotherapy sessions.”
Step 2: Map the “current best way” (not the ideal fantasy)
Interview the people who do the work. Ask:
- Where do errors happen?
- What do you do when equipment is missing?
- What do you document (and where)?
Write down reality first. Then improve it.
Step 3: Write the POP using a clear template (modelo de protocolo operacional padrão)
A practical protocolo operacional padrão modelo looks like this:
1) Title + code (optional)
Some organisations use internal numbering (you might see labels like “protocolo 101.01” or “protocolo P05”). Treat these as internal document IDs, not universal standards.
2) Purpose
One paragraph: what the POP achieves.
3) Scope
Where it applies (unit, team, shift, equipment type).
4) Definitions
Explain terms, abbreviations, and “edge cases.”
5) Responsibilities
List roles with verbs (e.g., “Nurse checks…,” “Technician records…”).
6) Materials/equipment
Include required items and acceptable substitutes.
7) Step-by-step procedure
Numbered steps. Short sentences. One action per line.
8) Safety and infection prevention
Reference the correct external guidance (e.g., WHO hand hygiene; CDC sterilisation rules; local ANVISA requirements where applicable).
9) Records and documentation
What must be recorded, where, and how long it’s retained (based on your institution’s policy).
10) Version control
Author, reviewer, approver, effective date, revision history.
Tip: once you finalise it, save a controlled protocolo operacional padrão PDF for distribution, but also keep an editable master with version control.
Step 4: Review and approve (hospital governance / EBSERH context)
If you work in a hospital network (including EBSERH units), approval often involves quality, nursing/medical leadership, and infection control, depending on the POP topic. Don’t skip approval workflows—especially for anything that affects patient safety or sterilisation.
(Practical note: each institution defines its own flow; use your internal governance rules and document control policy.)
Step 5: Train, then launch in the real workflow
Training works best when it happens:
- at the point of work,
- with the actual materials,
- during a real shift (not a classroom-only rollout).
Make the POP easy to access:
- QR code on the workstation
- laminated quick guide (one page)
- intranet + searchable title
Step 6: Monitor, improve, and update
A POP is not “done.” It’s controlled.
Track:
- adherence issues (what steps people skip and why)
- incident reports linked to the process
- Feedback from staff
- changes in equipment, suppliers, or regulations
If you work under an ISO-based quality system, “documented information” and controlled updates matter. ISO 9001 explains the need to maintain and control documented processes in a quality management system. (ISO overview: https://www.iso.org/iso-9001-quality-management.html)
POP examples by area (healthcare-focused)
Below are common POP categories. Use these as implementation ideas, not as clinical advice.
Protocolo Operacional Padrão in nursing (protocolo operacional padrão enfermagem)
High-value nursing POPs often cover:
- medication administration workflow (double checks, documentation steps)
- patient identification routines
- shift handover documentation
- fall-risk prevention actions (operational steps, not clinical protocol)
Keep these POPs aligned with your hospital’s patient safety policies and clinical protocols.
Protocolo Operacional Padrão in dentistry (protocolo operacional padrão odontologia)
Dental clinics benefit from POPs for:
- instrument reprocessing
- surface disinfection between patients
- management of sharps and waste
- patient record documentation
For infection control foundations in dental settings, the CDC’s dental infection control guidance offers a reputable baseline. (CDC dental infection control: Dental Infection Prevention and Control)
POP for sterilization and CME (protocolo operacional padrão esterilização / protocolo operacional padrão cme)
This is one of the most critical areas for POP quality.
Your POPs should cover:
- cleaning and inspection
- packaging and labeling
- sterilisation cycle selection and monitoring
- load release criteria
- traceability records
- handling nonconforming loads
Use authoritative references like:
- ANVISA RDC nº 15/2012 for Brazil (link above)
- CDC sterilisation guidance (link above)
POP in psychology (protocolo operacional padrão psicologia)
Psychology services often need POPs for operational consistency, such as:
- informed consent workflow (collection, storage, documentation)
- Privacy and confidentiality steps
- session notes, standards and retention
- crisis escalation workflow (handoff to medical team when required)
The POP here protects patients and professionals by reducing ambiguity and ensuring consistent documentation.
POP in physiotherapy (protocolo operacional padrão fisioterapia)
Useful physiotherapy POPs include:
- equipment cleaning between patients
- patient intake and contraindication checks (operational checklist + referral steps)
- documentation standards after each session
- incident escalation (pain event, fall, adverse reaction)
POP for SAMU operations (protocolo operacional padrão samu / protocolo operacional padrão samu 192)
Prehospital care teams often use POPs for:
- ambulance equipment checks (start of shift)
- oxygen cylinder handling
- vehicle cleaning/disinfection steps
- documentation and handoff routines
Clinical decision-making should follow the appropriate medical protocols, but the POP can standardise the operational execution.
Common POP mistakes (and quick fixes)
- Copying a modelo de protocolo operacional padrão without adapting it
Fix: interview staff and test the POP in one shift. - Writing for auditors instead of users
Fix: reduce paragraphs; use numbered steps and checklists. - No owner, no update cycle
Fix: assign one accountable role and define revision dates. - Too long to use at the workstation
Fix: create a 1-page “quick guide” plus the full controlled POP. - Confusing protocol with POP
Fix: separate “clinical protocol” references from “how-to procedure steps.”
Quick FAQ (because teams ask these every week)
What’s the plural of Protocolo Operacional Padrão? (plural de protocolo operacional padrão)
In Portuguese, you’ll commonly see “Protocolos Operacionais Padrão” or “Protocolos Operacionais Padronizados.” In daily use, teams often write “POPs” after defining the abbreviation once.
“Protocolo operacional padrão” ou “procedimento operacional padrão”?
In many Brazilian organisations, people use them as near-synonyms. In practice, pick one naming convention and apply it consistently in your document control system.
Are codes like “protocolo 101.01” or “protocolo P05” universal?
No. Treat them as internal identifiers. Always pair the code with the title, version, and effective date.
Final takeaway: implement one POP that people will actually follow
The best Protocolo Operacional Padrão is not the fanciest document. It’s the one that:
- fits the real workflow,
- reduces mistakes,
- and stays updated.
If your POP needs a POP to explain how to use it, you’ve gone too far.
If you want, tell me your setting (e.g., “POP for CME sterilisation,” “POP nursing medication,” “POP psychology intake”) and whether you need a one-page quick guide or a full SOP—and I’ll draft a clean modelo de protocolo operacional padrão you can adapt to your facility.