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Resources › Standard operating procedures (SOPs)
All standard operating procedures (sops) in one place, grouped by standard. Use the links to read a document, or download the PDF.
Standard 1: Assessment, Care Planning and Safety
| Document | Title | Criteria | |
|---|---|---|---|
| ID-SOP-001 | Patient Identification and Specimen Labelling | 1.1 | Download PDF |
| CON-SOP-001 | Informed Consent Before Significant Care | 1.3 | Download PDF |
| PSF-SOP-001 | Falls Risk Assessment and Prevention | 29.13, 48.1, 58.4, 61.1, 61.2 | Download PDF |
| EMG-SOP-001 | Fire Safety and Evacuation | 1.6 | Download PDF |
| STF-SOP-001 | Staff Credential Verification and Recheck | 5.6, 8.6, 28.22, 29.39 | Download PDF |
| PHM-SOP-001 | Medicine Storage and Temperature Monitoring | 17.6 | Download PDF |
| WST-SOP-001 | Sharps and Clinical Waste Management | 28.8, 31.11 | Download PDF |
| HH-SOP-001 | Hand Hygiene at the Point of Care | 1.2 | Download PDF |
| CLN-SOP-001 | Structured clinical assessment on admission | 1.2 | Download PDF |
| CLN-SOP-002 | Individualised care planning | 29.29 | Download PDF |
| CLN-SOP-003 | Nutritional risk screening and therapeutic diets | 1.5 | Download PDF |
| CLN-SOP-004 | Pressure injury risk assessment and prevention | 1.6 | Download PDF |
| CLN-SOP-005 | Venous thromboembolism risk assessment and prophylaxis | 1.7 | Download PDF |
Standard 2: Operating Theatre and Surgical Safety
| Document | Title | Criteria | |
|---|---|---|---|
| SRG-SOP-001 | Surgical safety checklist procedure | 55.4, 60.2, 60.6 | Download PDF |
| SRG-SOP-003 | Surgical site infection prevention bundle | 55.4, 60.4, 60.8 | Download PDF |
Standard 2A: Governance and Safety Culture
| Document | Title | Criteria | |
|---|---|---|---|
| GOV-SOP-001 | Governing Body Meetings and Decisions on Safety and Quality | 2A.1 | Download PDF |
| DIG-SOP-001 | Patient Data Breach Response Procedure | 2A.4 | Download PDF |
| INC-SOP-001 | Root Cause Analysis of Serious Incidents | 28.27 | Download PDF |
| QUA-SOP-001 | Safety Culture Survey Procedure | 2A.7 | Download PDF |
| CON-SOP-002 | In-Stay Patient Experience Feedback Procedure | 2A.8 | Download PDF |
| GOV-SOP-002 | Ethics Consultation Procedure | 2A.9 | Download PDF |
Standard 2B: Facility, Environment and Equipment
| Document | Title | Criteria | |
|---|---|---|---|
| ENV-SOP-001 | Accessible Reception and Registration Points | 2B.1 | Download PDF |
| ACC-SOP-001 | Queue and Wait-Time Management | 2B.2 | Download PDF |
| WAT-SOP-001 | Water Quality Testing and Safety | 2B.3 | Download PDF |
| EQP-SOP-001 | Medical Equipment Maintenance and Removal from Use | 2B.4 | Download PDF |
| ENV-SOP-002 | Cleaning of Shared Clinical and Waiting Areas | 2B.5 | Download PDF |
| FAC-SOP-001 | Facility Risk Management Procedure | 2B.6 | Download PDF |
| ENV-SOP-003 | Facility Signage Standard | 2B.8 | Download PDF |
| FAC-SOP-002 | Failure Logging and Analysis | 2B.9 | Download PDF |
| EQP-SOP-002 | Endoscope Reprocessing Standard | 2B.10 | Download PDF |
Standard 2C: Sustainability
| Document | Title | Criteria | |
|---|---|---|---|
| ENV-SOP-004 | Environmental Impact Review (leadership) | 28.7 | Download PDF |
| ENV-SOP-005 | Governance Reporting of Sustainability Progress | 27.12, 28.13 | Download PDF |
| PRC-SOP-001 | Procurement Stewardship Review | 28.9 | Download PDF |
| ENV-SOP-006 | Energy Use Monitoring and Reduction | 27.9, 28.10 | Download PDF |
| ENV-SOP-007 | Carbon Footprint Baseline Method | 27.8 | Download PDF |
| FAC-SOP-003 | Climate and Health Emergency Risk Assessment | 28.12 | Download PDF |
Standard 2D: Digital Care and AI
| Document | Title | Criteria | |
|---|---|---|---|
| DIG-SOP-002 | Digital Care System Assessment and Management | 28.14 | Download PDF |
| DIG-SOP-003 | Digital Care Access and Alternatives | 28.15 | Download PDF |
| AI-SOP-001 | AI Performance and Safety Monitoring | 27.3, 28.18 | Download PDF |
| AI-SOP-002 | Staff Consultation Before AI Introduction | 27.4, 28.19 | Download PDF |
| AI-SOP-003 | Informing Patients About AI-Supported Care | 28.21 | Download PDF |
Standard 2E: Workforce
| Document | Title | Criteria | |
|---|---|---|---|
| WRK-SOP-001 | Annual competency assessment procedure | 27.6, 29.30 | Download PDF |
| WRK-SOP-002 | Occupational exposure and needlestick response | 2E.3 | Download PDF |
| WRK-SOP-003 | Staff vaccination and immunisation | 2E.3 | Download PDF |
| WRK-SOP-004 | Support after distressing events | 2E.3 | Download PDF |
| WRK-SOP-005 | Staff grievance and investigation procedure | 2E.4 | Download PDF |
| WRK-SOP-006 | Violence and aggression prevention and response | 9.22, 29.22 | Download PDF |
| WRK-SOP-007 | Staff feedback survey and response | 2E.6 | Download PDF |
| WRK-SOP-008 | Analysis of sickness and attrition data | 2E.7 | Download PDF |
| WRK-SOP-009 | Workforce equity monitoring | 29.41, 29.44 | Download PDF |
| WRK-SOP-010 | Concern handling and protection from retaliation | 29.44 | Download PDF |
Standard 3: Medicines and Pain
| Document | Title | Criteria | |
|---|---|---|---|
| MNP-SOP-001 | Opioid prescribing review and diversion monitoring | 3.2, 10.2 | Download PDF |
| MNP-SOP-002 | Structured pain assessment and reassessment | 3.3 | Download PDF |
Standard 4: Environment and Accessibility
| Document | Title | Criteria | |
|---|---|---|---|
| ACS-SOP-001 | Environmental falls-risk survey and hazard control | 4.1, 4.5, 4.8 | Download PDF |
| ACS-SOP-002 | Beds and mobility equipment check | 4.6, 4.7, 28.5 | Download PDF |
Standard 5: Blood Bank
| Document | Title | Criteria | |
|---|---|---|---|
| BLD-SOP-001 | Donor selection, screening and deferral | 5.1 | Download PDF |
| BLD-SOP-002 | Donation testing and disposal of unsafe units | 5.2 | Download PDF |
| BLD-SOP-003 | Traceability and recall | 5.3 | Download PDF |
| BLD-SOP-004 | Cold chain storage and transport of blood | 5.4, 9.19 | Download PDF |
| BLD-SOP-005 | Adverse reactions in donors and recipients | 5.7 | Download PDF |
| BLD-SOP-006 | Emergency release of blood before full compatibility | 5.9 | Download PDF |
Standard 6: Day Clinic and Day Surgery
| Document | Title | Criteria | |
|---|---|---|---|
| DAY-SOP-001 | Recovery monitoring and discharge criteria | 6.3, 60.5 | Download PDF |
| DAY-SOP-002 | Sedation and anaesthesia level, and response to complications | 6.2, 60.3 | Download PDF |
| DAY-SOP-003 | Unplanned admission review | 6.7 | Download PDF |
| DAY-SOP-004 | Pre-procedure checks for day surgery | 6.5 | Download PDF |
Standard 7: Emergency Dispatch
| Document | Title | Criteria | |
|---|---|---|---|
| EDP-SOP-001 | Call triage using a recognised protocol | 7.2 | Download PDF |
| EDP-SOP-002 | Dispatch and pre-arrival instructions | 7.3 | Download PDF |
| EDP-SOP-003 | Call quality review | 7.7 | Download PDF |
| EDP-SOP-004 | Queued calls and escalation to a duty manager | 7.8 | Download PDF |
| EDP-SOP-005 | Clinical advice and escalation for call takers | 7.9 | Download PDF |
Standard 8: Fertility Clinic
| Document | Title | Criteria | |
|---|---|---|---|
| FRT-SOP-001 | Identification and traceability of gametes and embryos | 8.3 | Download PDF |
| FRT-SOP-002 | Monitored storage, alarms and back-up | 8.4 | Download PDF |
| FRT-SOP-003 | Donor screening for gametes and embryos | 8.5 | Download PDF |
| FRT-SOP-004 | Adverse event and ovarian hyperstimulation review | 8.7 | Download PDF |
| FRT-SOP-005 | Psychological support offer | 8.8 | Download PDF |
| FRT-SOP-006 | Gamete and embryo mix-up response | 8.9 | Download PDF |
| FRT-SOP-007 | Chain of custody for tissues and organs | 8.11 | Download PDF |
Standard 9: Field Hospital
| Document | Title | Criteria | |
|---|---|---|---|
| FLD-SOP-001 | Surge triage at peak patient volume | 9.2 | Download PDF |
| FLD-SOP-002 | Psychosocial support in the field | 9.10 | Download PDF |
| FLD-SOP-003 | Donated medicines and equipment: check before use | 9.12 | Download PDF |
| FLD-SOP-004 | Clinical response to sexual violence | 9.13 | Download PDF |
Standard 10: Hospice and Palliative Care
| Document | Title | Criteria | |
|---|---|---|---|
| HSP-SOP-001 | Family and carer support and information | 10.4 | Download PDF |
| HSP-SOP-002 | Spiritual, cultural and psychological needs | 10.5 | Download PDF |
| HSP-SOP-003 | Care of the dying patient | 10.6, 28.25, 35.8 | Download PDF |
| HSP-SOP-004 | Out-of-hours symptom advice | 10.10 | Download PDF |
| HSP-SOP-005 | Bereavement follow-up | 10.8, 28.27 | Download PDF |
Standard 11: Procedure Units, Endoscopy and Interventional Care
| Document | Title | Criteria | |
|---|---|---|---|
| PRO-SOP-001 | Verification and storage of procedure products | 11.2 | Download PDF |
| PRO-SOP-002 | Procedure consent and realistic outcomes | 11.4 | Download PDF |
| PRO-SOP-003 | Complications pathway and named contact | 11.5 | Download PDF |
| PRO-SOP-004 | Anaphylaxis and emergency response in procedure units | 11.6 | Download PDF |
| PRO-SOP-005 | Sterile technique and infection control in procedures | 11.7 | Download PDF |
| PRO-SOP-006 | Product recall and adverse reaction response | 11.9 | Download PDF |
Standard 12: Obstetrics and Gynaecology
| Document | Title | Criteria | |
|---|---|---|---|
| OBS-SOP-001 | Obstetric emergency response: haemorrhage and eclampsia | 12.3 | Download PDF |
| OBS-SOP-002 | Blood for obstetric emergencies | 12.4 | Download PDF |
| OBS-SOP-003 | Newborn care and resuscitation at birth | 12.5 | Download PDF |
| OBS-SOP-004 | Postnatal care and follow-up | 12.6 | Download PDF |
| OBS-SOP-006 | Obstetric early-warning response after birth | 12.10 | Download PDF |
| GYN-SOP-001 | Cervical and breast screening offer and follow-up | 12.13 | Download PDF |
| GYN-SOP-002 | Care after miscarriage and pregnancy loss | 12.14 | Download PDF |
Standard 13: Mobile Clinic and Outreach
| Document | Title | Criteria | |
|---|---|---|---|
| MOB-SOP-001 | Community consent and privacy | 13.6 | Download PDF |
| MOB-SOP-002 | Lone working check-in and response | 13.10 | Download PDF |
| MOB-SOP-003 | Coverage review and schedule change | 13.8 | Download PDF |
| MOB-SOP-004 | Vehicle readiness and roadworthiness before deployment | 13.9 | Download PDF |
Standard 14: Occupational Health
| Document | Title | Criteria | |
|---|---|---|---|
| OHS-SOP-001 | Health surveillance schedule | 14.3 | Download PDF |
| OHS-SOP-002 | Workplace advice | 14.5 | Download PDF |
| OHS-SOP-003 | Return-to-work plans | 14.6 | Download PDF |
| OHS-SOP-004 | Worker access to outcomes and review | 14.8 | Download PDF |
Standard 15: Optical and Hearing
| Document | Title | Criteria | |
|---|---|---|---|
| OPT-SOP-001 | Hygiene teaching for contact lens and hearing aid users | 15.4 | Download PDF |
| OPT-SOP-002 | Aftercare and follow-up for products | 15.5 | Download PDF |
| OPT-SOP-003 | Product complaints, returns and replacements | 15.6 | Download PDF |
Standard 16: Paediatric Care
| Document | Title | Criteria | |
|---|---|---|---|
| PED-SOP-001 | Weight measurement and dose check | 16.1, 16.11 | Download PDF |
| PED-SOP-002 | Immunisation and child health follow-up | 16.7 | Download PDF |
Standard 17: Pharmacy
| Document | Title | Criteria | |
|---|---|---|---|
| PHA-SOP-001 | Counselling on new medicines | 17.2 | Download PDF |
| PHA-SOP-002 | Stock management, shortages and expiry | 17.7 | Download PDF |
Standard 18: Physiotherapy
| Document | Title | Criteria | |
|---|---|---|---|
| PHY-SOP-001 | Measuring progress against goals | 18.4 | Download PDF |
Standard 19: Specimen Collection Point
| Document | Title | Criteria | |
|---|---|---|---|
| SPC-SOP-001 | Specimen transport | 19.4 | Download PDF |
| SPC-SOP-002 | Specimen rejection and requester notification | 19.5 | Download PDF |
| SPC-SOP-003 | Missing results follow-up | 19.7 | Download PDF |
Standard 21: Urgent Care
| Document | Title | Criteria | |
|---|---|---|---|
| URG-SOP-002 | Waiting-room re-check | 21.7 | Download PDF |
Standard 24: Medical Tourism
| Document | Title | Criteria | |
|---|---|---|---|
| MTR-SOP-001 | Travel and logistics support | 24.4 | Download PDF |
Standard 25: Health and Migration
| Document | Title | Criteria | |
|---|---|---|---|
| HMG-SOP-001 | Referral and handover to social services | 25.4 | Download PDF |
Standard 26: Dialysis and Renal Replacement
| Document | Title | Criteria | |
|---|---|---|---|
| DIA-SOP-001 | Preparation of concentrates and dialysis fluid | 26.3 | Download PDF |
Standard 27: Telemedicine
| Document | Title | Criteria | |
|---|---|---|---|
| TEL-SOP-001 | Remote clinician wellbeing and isolation check | 27.7 | Download PDF |
| TEL-SOP-002 | Patient identity and privacy at remote consultation | 27.13 | Download PDF |
| TEL-SOP-003 | Technical failure during a remote consultation | 27.17 | Download PDF |
Standard 28: Long-Term Care
| Document | Title | Criteria | |
|---|---|---|---|
| LTC-SOP-003 | Coordinating therapy with daily nursing and care | 28.2 | Download PDF |
| LTC-SOP-004 | Manual handling and staff injury prevention | 28.23 | Download PDF |
| LTC-SOP-005 | Dementia-related aggression: response | 28.24 | Download PDF |
Standard 29: Home Care
| Document | Title | Criteria | |
|---|---|---|---|
| HC-SOP-001 | Caregiver replacement request | 29.3 | Download PDF |
| HC-SOP-002 | Independent check-ins for abuse and neglect | 29.5 | Download PDF |
| HC-SOP-003 | Caregiver background screening, registries and recheck | 29.6, 29.7, 29.8, 29.9 | Download PDF |
| HC-SOP-004 | Home environment safety assessment and remediation | 29.11, 29.14 | Download PDF |
| HC-SOP-005 | Medication changes, transitions and missed doses | 29.18, 29.20 | Download PDF |
| HC-SOP-006 | Medicines in multi-person households | 29.19 | Download PDF |
| HC-SOP-007 | Lone-worker check-in and discreet distress signal | 29.34 | Download PDF |
| HC-SOP-008 | Supervisory visits in the home | 29.26, 29.27 | Download PDF |
| HC-SOP-009 | Coverage for a solo caregiver's absence | 29.31 | Download PDF |
| HC-SOP-010 | New caregiver support in the first 100 days | 29.33 | Download PDF |
| HC-SOP-011 | Incident reporting for delayed discovery in the home | 29.35 | Download PDF |
| HC-SOP-012 | Caregiver work authorisation change: transition support | 29.40 | Download PDF |
| HC-SOP-013 | Continuity of care when a client relocates | 29.45 | Download PDF |
Standard 30: Fitness and Wellness
| Document | Title | Criteria | |
|---|---|---|---|
| FW-SOP-001 | Return-to-activity programme after injury | 30.2 | Download PDF |
| FW-SOP-002 | Warning signs and stop protocol | 30.5 | Download PDF |
| FW-SOP-003 | Pre-participation screening | 30.7 | Download PDF |
| FW-SOP-004 | Exercise supervision and instruction | 30.8 | Download PDF |
Standard 31: Dental Care
| Document | Title | Criteria | |
|---|---|---|---|
| DEN-SOP-001 | Sterilisation of reusable dental instruments | 31.1 | Download PDF |
| DEN-SOP-002 | Dental unit waterline management | 31.5 | Download PDF |
| DEN-SOP-003 | Aerosol and splatter control | 31.7 | Download PDF |
| DEN-SOP-004 | Dental amalgam waste and mercury handling | 31.10 | Download PDF |
| DEN-SOP-005 | Dental medical emergency response | 31.13 | Download PDF |
| DEN-SOP-006 | Minor oral surgery: assessment, consent and follow-up | 31.16 | Download PDF |
| DEN-SOP-007 | Dental laboratory work specification, traceability and disinfection | 31.21 | Download PDF |
| DEN-SOP-008 | Care of children and people with special needs | 31.23 | Download PDF |
Standard 32: Aesthetic and Cosmetic Procedures (non-surgical only)
| Document | Title | Criteria | |
|---|---|---|---|
| AES-SOP-001 | Consent, realistic outcomes and reconsideration | 32.2 | Download PDF |
| AES-SOP-002 | Pre-procedure assessment and contraindications | 32.3 | Download PDF |
| AES-SOP-003 | Sedation and anaesthesia safety | 32.4 | Download PDF |
| AES-SOP-004 | Follow-up and complication management | 32.6 | Download PDF |
Standard 33: Laboratory
| Document | Title | Criteria | |
|---|---|---|---|
| LBT-SOP-001 | Method validation before clinical use | 33.3 | Download PDF |
| LBT-SOP-002 | Internal quality control | 33.4 | Download PDF |
| LBT-SOP-010 | Test information for users | 33.6 | Download PDF |
| LBT-SOP-003 | Specimen acceptance and rejection | 33.7 | Download PDF |
| LBT-SOP-004 | Specimen transport | 33.8 | Download PDF |
| LBT-SOP-005 | STAT specimens and turnaround | 33.9 | Download PDF |
| LBT-SOP-006 | Chain of custody for forensic and legal specimens | 33.10 | Download PDF |
| LBT-SOP-007 | Critical value communication | 33.11 | Download PDF |
| LBT-SOP-008 | Laboratory report content and delivery | 33.13 | Download PDF |
| LBT-SOP-009 | Result amendments | 33.14 | Download PDF |
Standard 34: Rehabilitation
| Document | Title | Criteria | |
|---|---|---|---|
| REH-SOP-001 | Multidisciplinary rehabilitation team coordination | 34.2 | Download PDF |
| REH-SOP-002 | Patient and family goal-setting and expectations | 34.3 | Download PDF |
| REH-SOP-003 | Assistive device assessment, provision and training | 34.5 | Download PDF |
| REH-SOP-004 | Discharge and community reintegration planning | 34.6 | Download PDF |
| REH-SOP-005 | Written aftercare plan at discharge | 34.8, 34.9 | Download PDF |
Standard 35: Critical Care
| Document | Title | Criteria | |
|---|---|---|---|
| CRT-SOP-001 | Critical care monitoring and alarm settings | 35.1 | Download PDF |
| CRT-SOP-002 | Rapid response and escalation | 35.3, 35.7 | Download PDF |
| CRT-SOP-003 | Family communication and presence | 35.5 | Download PDF |
Standard 36: Hospital Emergency Department
| Document | Title | Criteria | |
|---|---|---|---|
| ED-SOP-003 | Patients who leave before assessment | 36.5 | Download PDF |
Standard 37: Neonatal and Paediatric Hospital Care
| Document | Title | Criteria | |
|---|---|---|---|
| NEO-SOP-002 | NEO-SOP-002 | 37.1 | Download PDF |
| NEO-SOP-003 | NEO-SOP-003 | 37.3 | Download PDF |
| NEO-SOP-004 | NEO-SOP-004 | 37.4 | Download PDF |
| NEO-SOP-005 | NEO-SOP-005 | 37.5 | Download PDF |
Standard 38: Substance Use and Addiction Treatment
| Document | Title | Criteria | |
|---|---|---|---|
| SUB-SOP-001 | Validated substance use assessment | 38.1 | Download PDF |
| SUB-SOP-002 | Harm reduction services and naloxone access | 38.3 | Download PDF |
| SUB-SOP-003 | Discharge, community support and relapse plan | 38.5 | Download PDF |
Standard 40: Nutrition and Dietetics
| Document | Title | Criteria | |
|---|---|---|---|
| NUT-SOP-001 | Malnutrition identification and monitoring | 40.3 | Download PDF |
| NUT-SOP-002 | Diet texture from swallowing assessment | 40.4 | Download PDF |
Standard 41: Complementary and Traditional Medicine
| Document | Title | Criteria | |
|---|---|---|---|
| TRM-SOP-001 | Disclosure of evidence to patients | 41.2 | Download PDF |
| TRM-SOP-002 | Referral to conventional care and warning signs | 41.3 | Download PDF |
Standard 42: Aftercare, Follow-Up and Post-Discharge Safety
| Document | Title | Criteria | |
|---|---|---|---|
| AFT-SOP-001 | High-risk patient contact after discharge | 42.3 | Download PDF |
| AFT-SOP-002 | Written warning signs and urgent help route | 42.4 | Download PDF |
Standard 43: Organ and Tissue Transplant
| Document | Title | Criteria | |
|---|---|---|---|
| TXP-SOP-001 | Recipient evaluation and consent | 43.4 | Download PDF |
| TXP-SOP-003 | Post-transplant follow-up and outcome tracking | 43.6 | Download PDF |
Standard 44: Access, Findability and Wayfinding
| Document | Title | Criteria | |
|---|---|---|---|
| WAY-SOP-001 | Emergency entrance marking and access | 44.2 | Download PDF |
| WAY-SOP-003 | Route marking and user testing | 44.4 | Download PDF |
Standard 45: Reception, Waiting and Health Information
| Document | Title | Criteria | |
|---|---|---|---|
| WTG-SOP-001 | Keeping waiting patients informed | 45.3 | Download PDF |
| WTG-SOP-002 | Writing plain-language health information | 45.4 | Download PDF |
| WTG-SOP-003 | WTG-SOP-003 | 45.2 | Download PDF |
Standard 46: Hospital Disaster and Emergency Preparedness
| Document | Title | Criteria | |
|---|---|---|---|
| DIS-SOP-001 | Hazard and vulnerability assessment | 46.2 | Download PDF |
| DIS-SOP-003 | Review after plan activation | 46.5 | Download PDF |
Standard 47: Sepsis, Clinical Deterioration and Venous Thromboembolism
| Document | Title | Criteria | |
|---|---|---|---|
| DET-SOP-002 | Review of deterioration, sepsis and VTE events | 47.5 | Download PDF |
Standard 48: Falls, Pressure Injury and Safe Handover
| Document | Title | Criteria | |
|---|---|---|---|
| PRS-SOP-001 | Pressure injury staging, treatment and recording | 48.2, 48.3 | Download PDF |
| HOV-SOP-001 | Review of falls, pressure injury and handover events | 48.5, 61.5 | Download PDF |
Standard 49: Advance Care Planning, Palliative Needs and Dignity
| Document | Title | Criteria | |
|---|---|---|---|
| PAL-SOP-001 | Palliative needs identification | 49.3 | Download PDF |
| DGN-SOP-002 | DGN-SOP-002 | 49.5 | Download PDF |
Standard 50: Diagnostic Imaging
| Document | Title | Criteria | |
|---|---|---|---|
| IMG-SOP-001 | Imaging equipment quality assurance and calibration | 50.2 | Download PDF |
| CTR-SOP-001 | Contrast media safety protocol | 50.4 | Download PDF |
| MRI-SOP-001 | MRI safety screening and zone control | 50.5 | Download PDF |
Standard 51: Oncology and Cancer Care
| Document | Title | Criteria | |
|---|---|---|---|
| ONC-SOP-001 | Cytotoxic drug safe handling | 51.1 | Download PDF |
| ONC-SOP-002 | Chemotherapy independent two-person check | 51.2, 51.7 | Download PDF |
| ONC-SOP-003 | Neutropenic fever response | 51.3, 51.9 | Download PDF |
| ONC-SOP-004 | Extravasation recognition and immediate management | 51.4 | Download PDF |
| ONC-SOP-005 | ONC-SOP-005 | 51.6 | Download PDF |
| ONC-SOP-006 | ONC-SOP-006 | 51.7 | Download PDF |
| ONC-SOP-007 | ONC-SOP-007 | 51.8 | Download PDF |
| ONC-SOP-008 | ONC-SOP-008 | 51.9 | Download PDF |
| ONC-SOP-009 | ONC-SOP-009 | 51.10 | Download PDF |
Standard 52: Psychiatry and Mental Health
| Document | Title | Criteria | |
|---|---|---|---|
| PSY-SOP-001 | Suicide risk screening and continuous observation | 52.1 | Download PDF |
| PSY-SOP-002 | Psychiatric medicines: interaction and monitoring protocol | 52.4 | Download PDF |
| PSY-SOP-003 | PSY-SOP-003 | 52.3 | Download PDF |
Standard 53: Allergology
| Document | Title | Criteria | |
|---|---|---|---|
| ALR-SOP-001 | Allergy history taking and recording | 53.1 | Download PDF |
| ALR-SOP-002 | Anaphylaxis recognition and treatment | 53.2 | Download PDF |
| ALR-SOP-003 | Allergen testing quality control and interpretation | 53.3 | Download PDF |
| ALR-SOP-004 | Allergy results communication and action plan | 53.5 | Download PDF |
Standard 54: Dermatology and Skin Clinics
| Document | Title | Criteria | |
|---|---|---|---|
| DRM-SOP-001 | Skin lesion examination and urgent referral | 54.1 | Download PDF |
| DRM-SOP-002 | Sterile technique for minor skin procedures | 54.2 | Download PDF |
| DRM-SOP-003 | Systemic dermatology drug monitoring | 54.4 | Download PDF |
| DRM-SOP-004 | Written aftercare and pathology follow-up | 54.5 | Download PDF |
Standard 55: Cosmetic and Plastic Surgery
| Document | Title | Criteria | |
|---|---|---|---|
| PLS-SOP-001 | Pre-operative suitability and risk assessment | 55.1 | Download PDF |
| PLS-SOP-002 | Recovery, discharge and follow-up after plastic surgery | 55.5 | Download PDF |
Standard 56: Cardiology, Outpatient and Cardiac Procedures
| Document | Title | Criteria | |
|---|---|---|---|
| CAR-SOP-001 | Cardiac risk assessment before investigation or procedure | 56.1 | Download PDF |
| CAR-SOP-002 | Cardiac procedure safety standard | 56.2 | Download PDF |
| CAR-SOP-003 | Cardiac follow-up and risk reduction plan | 56.5 | Download PDF |
Standard 57: Radiotherapy
| Document | Title | Criteria | |
|---|---|---|---|
| RTH-SOP-001 | Treatment plan verification before the first fraction | 57.1 | Download PDF |
| RTH-SOP-002 | Patient identity and site verification before each fraction | 57.2 | Download PDF |
| RTH-SOP-003 | Linear accelerator quality assurance | 57.3 | Download PDF |
Standard 58: Inpatient Ward Care
| Document | Title | Criteria | |
|---|---|---|---|
| WRD-SOP-001 | Admission assessment and daily review on the ward | 58.1 | Download PDF |
| WRD-SOP-002 | Ward medicine administration checks | 58.2 | Download PDF |
Standard 59: Outpatient Medical Specialties
| Document | Title | Criteria | |
|---|---|---|---|
| OMS-SOP-001 | Specialist consultation: assessment, consent and clinician scope | 59.2 | Download PDF |
| OMS-SOP-003 | OMS-SOP-003 | 59.3 | Download PDF |
Standard 60: Surgical and Specialty Clinics
| Document | Title | Criteria | |
|---|---|---|---|
| SSC-SOP-001 | Surgeon privileges and operating list check | 60.1 | Download PDF |
| SRG-SOP-002 | SRG-SOP-002 | 60.2 | Download PDF |
Standard 62: Penitentiary Health Services
| Document | Title | Criteria | |
|---|---|---|---|
| PNT-SOP-001 | Reception health screening and medical examination | 62.1 | Download PDF |
Standard 63: Safe Handover
| Document | Title | Criteria | |
|---|---|---|---|
| SHO-SOP-001 | Safe handover procedure: when and how clinicians hand over care | 58.5, 63.1, 63.2, 63.3, 63.4 | Download PDF |
Standard BASIS: System BASIS
| Document | Title | Criteria | |
|---|---|---|---|
| SIR-SOP-001 | Serious incident investigation procedure | B2.6 | Download PDF |
| PCA-SOP-001 | Policy compliance audit procedure | B2.3 | Download PDF |
| PFB-SOP-001 | Annual patient feedback procedure | B2.7 | Download PDF |
Standard S1: Hospital
| Document | Title | Criteria | |
|---|---|---|---|
| HOS-SOP-001 | Emergency triage | 9.14, 36.1 | Download PDF |
| HOS-SOP-002 | Vital signs and deterioration response | 12.15, 58.3 | Download PDF |
| HOS-SOP-003 | Sepsis recognition and antibiotic timing | Download PDF | |
| HOS-SOP-004 | Structured verbal handover | Download PDF | |
| HOS-SOP-005 | Medicine storage and temperature control | Download PDF | |
| HOS-SOP-006 | High-alert medicines | Download PDF | |
| HOS-SOP-007 | Medicines reconciliation | Download PDF | |
| HOS-SOP-008 | Blood transfusion | 9.19 | Download PDF |
| HOS-SOP-009 | Critical result reporting | Download PDF | |
| HOS-SOP-010 | Discharge and aftercare planning | Download PDF | |
| HOS-SOP-011 | Post-discharge follow-up | 11.8 | Download PDF |
| HOS-SOP-012 | Internal emergency alert codes | Download PDF | |
| HOS-SOP-013 | Vulnerable patients and safeguarding | 9.23 | Download PDF |
| HOS-SOP-014 | Healthcare-associated infection surveillance and response | 6.6 | Download PDF |
| HOS-SOP-015 | Resuscitation equipment checks | 50.7 | Download PDF |
| HOS-SOP-016 | Electronic system downtime | Download PDF |
Standard S2: Ambulatory clinic
| Document | Title | Criteria | |
|---|---|---|---|
| AMC-SOP-001 | Clinic emergency response and transfer to hospital | Download PDF |
Standard S3: Primary care practice
| Document | Title | Criteria | |
|---|---|---|---|
| PHC-SOP-001 | Routing conditions not managed by the practice | Download PDF | |
| PHC-SOP-002 | Continuity of care and shared records | Download PDF | |
| PHC-SOP-003 | Referral criteria and referral tracking | 13.7, 59.1 | Download PDF |
| PHC-SOP-004 | Chronic condition care plans and recall | Download PDF | |
| PHC-SOP-005 | Population data review | Download PDF | |
| PHC-SOP-006 | Screening offer and follow-up | Download PDF |
Standard S4: Long-term care
| Document | Title | Criteria | |
|---|---|---|---|
| LTC-SOP-001 | Falls, pressure injury and nutrition risk screening | Download PDF | |
| LTC-SOP-002 | Medicine reconciliation at admission, transfer and discharge | Download PDF |
Standard S5: Ambulance and patient transport
| Document | Title | Criteria | |
|---|---|---|---|
| AMT-SOP-001 | Transfer logging, handover and record keeping | Download PDF | |
| AMT-POL-001 | Partner operators: agreement and certificate check | Download PDF | |
| AMT-SOP-002 | Receiving hospital agreement and acceptance | Download PDF |
Standard S6: Patient transfers and referrals
| Document | Title | Criteria | |
|---|---|---|---|
| PTR-SOP-001 | Transfer planning | 9.20 | Download PDF |
| PTR-SOP-002 | Care level classification and crew matching | Download PDF | |
| PTR-SOP-003 | Neonatal, paediatric and critical transfers | Download PDF | |
| PTR-SOP-004 | Air transport planning and authorisation | Download PDF | |
| PTR-SOP-005 | Escort and crew competence and escort handover | Download PDF | |
| PTR-SOP-006 | In-transit monitoring, deterioration and dispatch updates | Download PDF | |
| PTR-SOP-007 | Structured handover at each change of segment | Download PDF | |
| PTR-SOP-008 | Infection control, isolation, PPE and waste in transit | Download PDF | |
| PTR-SOP-009 | Crew exposure to blood, needle injury or infection | Download PDF | |
| PTR-SOP-010 | Communication, interpreters and records in another language | 29.37, 29.42 | Download PDF |
| PTR-SOP-011 | Driver training and fatigue management | Download PDF | |
| PTR-SOP-012 | Contingency, breakdown, surge and diversion | 9.20 | Download PDF |
| PTR-SOP-013 | Consent and the right to decline transport | Download PDF |