Advisory AS18/01: Advice on not applicable actions

5 June 2025

To clarify not applicable actions for hospitals, day procedure services, multi-purpose services and Community Healthcare Services.

Advisory details

Item	Details
Advisory number	AS18/01
Version number	11.0
Publication date	5 June 2025
Replaces	AS18/01 version 10.0 published on July 2021
Compliance with this advisory	It is mandatory for approved accrediting agencies to implement this Advisory
Information in this advisory applies to	All approved accrediting agencies All health service organisations
Key relationship	All NSQHS Standards
Attachment	Summary tables of not applicable actions
Notes	Updated not applicable actions for Community Healthcare Services implementing the NSQHS Standards. Update to Actions 4.10 and 4.12 for DPS Removal of: Transport Services, see: Advisory AS23/02: Advice on not applicable actions for Ambulance Health Services Private Dental Services, see here Bush Nursing services accredited to the National Safety and Quality Primary and Community Healthcare Standards, see here For other National Safety and Quality Standards: Cosmetic Surgery, see: CS25/02: Advice on not applicable actions for the Cosmetic Surgery Standards National Safety and Quality Digital Mental Health (NSQDMH) Standards, see Not applicable actions in the NSQDMH Standards National Safety and Quality Mental Health Standards for Community Managed Organisations, see: NSQMHCMO Standards Advisory CMO 24/01 - Advice on not applicable actions
Responsible officer	Margaret Banks Director, National Standards Phone: 1800 304 056 Email: AdviceCentre@safetyandquality.gov.au
To be reviewed	December 2027

Purpose

To clarify not applicable actions for hospitals, day procedure services, multi-purpose services, community healthcare services and public dental services.

Issue

In some exceptional circumstances, actions from the NSQHS Standards may not be applicable to a health service organisation. The Commission has issued this advisory to ensure the consistent application of not applicable status to actions within the NSQHS Standards.

Requirements

The attached summary tables detail the actions which may be awarded not applicable rating, subject to supporting evidence being provided by the health service organisation.

Where a health service organisation considers that an action is not applicable, evidence must be supplied to demonstrate that the action is associated with little or no risk of patient harm in their service context. Applications should be submitted to the approved accrediting agency well in advance of the assessment. Accrediting agencies are to provide an initial determination of the health service organisation’s submission before undertaking the scheduled assessment. At assessment, assessors are to verify that the decision to award these actions not applicable status is justified.

Accrediting agencies are required to refer to the tables below when considering applications from health service organisations for non-applicability of actions within the NSQHS Standards.

In large organisations, there may be specific units or departments where an action does not apply, while remaining applicable elsewhere in the organisation. For example, Action 3.12 regarding invasive devices may not be relevant in a sleep lab or rehabilitation unit. In these cases, the action will apply for the health service organisation but is not required to be assessed for units where it is demonstrated as not applicable.

Infrequent application of an action, such as applying Action 3.05 Surveillance strategies for antimicrobial use in patient transport services or Action 7.06 Prescribing and administering blood and blood products, is not sufficient reason for awarding not applicable status. Where an action is infrequently applied, strategies to implement the action are likely to be a simple monitoring and review process by the health service organisation.

Where there is a dispute concerning an award of not applicable status that is not resolved following discussions between the health service organisation and the accrediting agency, application can be made by either the accrediting agency or health service organisations to the Commission for mediation.

Aboriginal and Torres Strait Islander specific actions

Please refer to Advisory AS18/04: Advice on the applicability of Aboriginal and Torres Strait Islander specific actions for further details on applying for not applicable status.

Multi-Purpose Services Aged Care Module

The MPS Aged Care Module describes in six actions the requirements of the Aged Care Quality Standards not covered by the NSQHS Standards and applies only to MPS that are part of the Commonwealth MPS program.

Cosmetic Surgery Module

The Cosmetic Surgery Module outlines 20 actions that Services are required to implement in addition to the NSQHS Standards, allowing them to comply with both the NSQHS Standards (2nd Edition) and the Cosmetic Surgery Standards.

Attachment: Summary tables of not applicable actions

Clinical Governance Standard

Action	Applicability to
Action	Hospitals	Day procedure services	Multi Purpose services	Community Healthcare Services		Public Dental services
1.01	No exclusion	No exclusion	No exclusion	No exclusion		No exclusion
1.02	Not applicable for private sector hospitals that provide evidence that the risk of harm to Aboriginal and Torres Strait Islander patients is the same as for the organisation’s general patient population. No exclusion for hospitals operating under public- private partnerships (PPP) agreements or public hospitals.	Not applicable when evidence is provided that the risk of harm to Aboriginal and Torres Strait Islander patients is the same as for the organisation’s general patient population.	No exclusion	No exclusion		Not applicable when evidence is provided that the risk of harm to Aboriginal and Torres Strait Islander patients is the same as for the organisation’s general patient population
1.03	No exclusion	No exclusion	No exclusion	No exclusion		No exclusion
1.04	Not applicable for private sector hospitals that provide evidence that the risk of harm to Aboriginal and Torres Strait Islander patients is the same as for the organisation’s general patient population. No exclusion for hospitals operating under PPP agreements or public hospitals. See Advisory 18/04 Advice on the applicability of Aboriginal and Torres Strait Islander specific actions	Not applicable when evidence is provided that the risk of harm to Aboriginal and Torres Strait Islander patients is the same as for the organisation’s general patient population.	No exclusion	No exclusion		Not applicable when evidence is provided that the risk of harm to Aboriginal and Torres Strait Islander patients is the same as for the organisation’s general patient population
1.05	No exclusion	No exclusion	No exclusion	No exclusion		No exclusion
1.06	No exclusion	No exclusion	No exclusion	No exclusion		No exclusion
1.07	No exclusion	No exclusion	No exclusion	No exclusion		No exclusion
1.08	No exclusion	No exclusion	No exclusion	No exclusion		No exclusion
1.09	No exclusion	No exclusion	No exclusion	No exclusion		No exclusion
1.10	No exclusion	No exclusion	No exclusion	No exclusion		No exclusion
1.11	No exclusion	No exclusion	No exclusion	No exclusion		No exclusion
1.12	No exclusion	No exclusion	No exclusion	No exclusion		No exclusion
1.13	No exclusion	No exclusion	No exclusion	No exclusion		No exclusion
1.14	No exclusion	No exclusion	No exclusion	No exclusion		No exclusion
1.15	No exclusion	No exclusion	No exclusion	No exclusion		No exclusion
1.16	No exclusion	No exclusion	No exclusion	No exclusion		No exclusion
1.17	No exclusion	No exclusion	No exclusion	No exclusion		No exclusion
1.18	Not applicable when evidence is provided that the My Health Records system is not in use.	Not applicable when evidence is provided that the My Health Records system is not in use.	Not applicable when evidence is provided that the My Health Records system is not in use.	Not applicable when evidence is provided that the My Health Records system is not in use.		Not applicable when evidence is provided that the My Health Records system is not in use.
1.19	No exclusion	No exclusion	No exclusion	No exclusion		No exclusion
1.20	No exclusion	No exclusion	No exclusion	No exclusion		No exclusion
1.21	No exclusion	No exclusion	No exclusion	No exclusion		No exclusion
1.22	No exclusion	No exclusion	No exclusion	No exclusion		No exclusion
1.23	No exclusion	No exclusion	No exclusion	No exclusion		No exclusion
1.24	No exclusion	No exclusion	No exclusion	No exclusion		No exclusion
1.25	No exclusion	No exclusion	No exclusion		No exclusion	No exclusion
1.26	No exclusion	No exclusion	No exclusion		No exclusion	No exclusion
1.27	No exclusion	No exclusion	No exclusion		No exclusion	No exclusion
1.28	No exclusion	No exclusion	No exclusion		No exclusion	No exclusion
1.29	No exclusion	No exclusion	No exclusion		No exclusion	No exclusion
1.30	No exclusion	No exclusion	No exclusion		No exclusion	No exclusion
1.31	No exclusion	No exclusion	No exclusion		No exclusion	No exclusion
1.32	No exclusion	Not applicable for day procedure services that do not admit patients overnight	Not Applicable		Not applicable for bush nursing services that do not admit patients overnight	Not applicable
1.33	Not applicable for private sector hospitals that provide evidence that the risk of harm to Aboriginal and Torres Strait Islander patients is the same as for the organisation’s general patient population. No exclusion for hospitals operating under PPP agreements or public hospitals.	Not applicable when evidence is provided that the risk of harm to Aboriginal and Torres Strait Islander patients is the same as for the organisation’s general patient population.	No exclusion		No exclusion	Not applicable when evidence is provided that the risk of harm to Aboriginal and Torres Strait Islander patients is the same as for the organisation’s general population

Partnering with Consumers Standard

Action	Applicability to
Action	Hospitals	Day procedure services	Multi Purpose services	Community Healthcare Services	Public Dental services
2.01	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
2.02	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
2.03	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
2.04	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
2.05	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
2.06	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
2.07	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
2.08	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
2.09	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
2.10	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
2.11	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
2.12	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
2.13	Not applicable for private sector hospitals that provide evidence that the risk of harm to Aboriginal and Torres Strait Islander patients is the same as for the organisation’s general patient population. No exclusion for hospitals operating under PPP agreements or public hospitals.	Not applicable when evidence is provided that the risk of harm to Aboriginal and Torres Strait Islander patients is the same as for the organisation’s general patient population.	No exclusion	See Advisory 18/04 Advice on the applicability of Aboriginal and Torres Strait Islander specific actions	Not applicable when evidence is provided that the risk of harm to Aboriginal and Torres Strait Islander patients is the same as for the organisation’s general patient population
2.14	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion

Preventing and Controlling Infections Standard

Action	Applicability to
Action	Hospitals	Day procedure services	Multi-purpose services	Community Healthcare Services	Public Dental services
3.01	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
3.02	No exclusion	No exclusion	No exclusion	3.02 d, e and f - Not applicable if the organisation provides evidence they do not store, dispense, or prescribe antimicrobials	No exclusion
3.03	No exclusion	No exclusion	No exclusion	3.03 d, e and f - Not applicable if the organisation provides evidence they do not store, dispense, or prescribe antimicrobials	No exclusion
3.04	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
3.05	No exclusion	No exclusion	No exclusion	3.05 e, f and h - Not applicable if the organisation provides evidence they do not store, dispense, or prescribe antimicrobials	No exclusion
3.06	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
3.07	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
3.08	No exclusion	No exclusion	No exclusion	3.08c Not applicable when evidence is provided that the service only provides in home care	No exclusion
3.09	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
3.10	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
3.11	No exclusion	No exclusion	No exclusion	Not applicable when evidence is provided that the service does not perform aseptic technique	No exclusion
3.12	Not applicable when evidence is provided that a health service organisation does not use invasive devices	Not applicable when evidence is provided that a day procedure service does not use invasive devices	Not applicable when evidence is provided that a multi-purpose service does not use invasive devices	Not applicable when evidence is provided that the service does not use invasive devices	Not applicable when evidence is provided that a dental service does not use invasive devices
3.13	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
3.14	No exclusion	No exclusion	No exclusion	3.14 d Not applicable when evidence is provided that the service does not handle, transport or store linen	No exclusion
3.15	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
3.16	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
3.17	a. Not applicable if single-use items only are in use, includes all levels of reusable clinical equipment and instrumentation b. Not applicable if single-use items only are in use for critical and semi-critical equipment, instruments and devices	a. Not applicable if single-use items only are in use, includes all levels of reusable clinical equipment and instrumentation b. Not applicable if single-use items only are in use for critical and semi-critical equipment, instruments and devices	a. Not applicable if single-use items only are in use, includes all levels of reusable clinical equipment and instrumentation b. Not applicable if single-use items only are in use for critical and semi-critical equipment, instruments and devices	a. Not applicable if single-use items only are in use, includes all levels of reusable clinical equipment and instrumentation b. Not applicable if single-use items only are in use for critical and semi-critical equipment, instruments and devices	a. Not applicable if single-use items only are in use, includes all levels of reusable clinical equipment and instrumentation b. Not applicable if single-use items only are in use for critical and semi-critical equipment, instruments and devices
3.18	Not applicable when evidence is provided that a health service organisation does not administer or prescribe antimicrobials	Not applicable when evidence is provided that a health service organisation does not administer or prescribe antimicrobials	Not applicable when evidence is provided that a health service organisation does not administer or prescribe antimicrobials	Not applicable when evidence is provided that the service does not administer or prescribe antimicrobials	Not applicable when evidence is provided that a health service organisation does not administer or prescribe antimicrobials
3.19	Not applicable when evidence is provided that a health service organisation does not administer or prescribe antimicrobials	Not applicable when evidence is provided that a health service organisation does not administer or prescribe antimicrobials	Not applicable when evidence is provided that a health service organisation does not administer or prescribe antimicrobials	Not applicable when evidence is provided that the service does not administer or prescribe antimicrobials	Not applicable when evidence is provided that a health service organisation does not administer or prescribe antimicrobials

Medication Safety Standard

Action	Applicability to
Action	Hospitals	Day procedure services	MultiPurpose services	Community Healthcare Services	Public Dental services
4.01	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
4.02	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
4.03	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
4.04	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
4.05	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
4.06	No exclusion	Not applicable for day procedure services that provide evidence that they are not changing or altering patients’ medicines during an episode of care	No exclusion	Not applicable for services that provide evidence that they are not changing or altering patients’ medicines during an episode of care	Not applicable when evidence is provided that patient’s medicines are not changed or altered during an episode of care
4.07	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
4.08	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
4.09	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
4.10	No exclusion	Not applicable when evidence is provided that patient’s medicines are not changed or altered during an episode of care	No exclusion	Not applicable when evidence is provided that patient’s medicines are not changed or altered during an episode of care	Not applicable when evidence is provided that patient’s medicines are not changed or altered during an episode of care
4.11	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
4.12	No exclusion	Not applicable for day procedure services that provide evidence that they are not changing or altering patients’ medicines during an episode of care	No exclusion	Not applicable for services that provide evidence that they are not changing or altering patients’ medicines during an episode of care	Not applicable when evidence is provided that patient’s medicines are not changed or altered during an episode of care
4.13	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
4.14	No exclusion	a. No exclusion b. Not applicable when evidence is provided that the service does not procure and store temperature-sensitive medicines c. No exclusion	No exclusion	a. No exclusion b. Not applicable when evidence is provided that the service does not procure and store temperature-sensitive medicines c. No exclusion	a. No exclusion b. Not applicable when evidence is provided that the service does not procure and store temperature-sensitive medicines c. No exclusion
4.15	No exclusion	a. No exclusion	No exclusion	No exclusion	a. No exclusion

Comprehensive Care Standard

Action	Applicability to
Action	Hospitals	Day procedure services	Multi-purpose services	Community Healthcare Services	Public Dental services
5.01	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
5.02	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
5.03	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
5.04	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
5.05	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
5.06	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
5.07	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
5.08	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
5.09	No exclusion	Not applicable	No exclusion	Not applicable for services that do not provide care to patients at the end of life	Not applicable
5.10	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
5.11	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
5.12	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
5.13	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
5.14	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
5.15	No exclusion	Not applicable for day procedure services that do not provide care to patients at the end of life	No exclusion	Not applicable for services that do not provide care to patients at the end of life	Not applicable
5.16	No exclusion	Not applicable for day procedure services that do not provide care to patients at the end of life	No exclusion	Not applicable for services that do not provide care to patients at the end of life	Not applicable
5.17	No exclusion	No exclusion	No exclusion	No exclusion	Not applicable
5.18	No exclusion	Not applicable for day procedure services that do not provide care to patients at the end of life	No exclusion	Not applicable for services that do not provide care to patients at the end of life	Not applicable
5.19	No exclusion	Not applicable for day procedure services that do not provide care to patients at the end of life	No exclusion	No exclusion	Not applicable
5.20	No exclusion	Not applicable for day procedure services that do not provide care to patients at the end of life	No exclusion	Not applicable for services that do not provide care to patients at the end of life	Not applicable
5.21	No exclusion	Not applicable when evidence is provided by the health service organisation that they have had no incidents of pressure injuries over the preceding 12 months	No exclusion	Not applicable when evidence is provided that they have had no incidents of pressure injuries over the preceding 12 months	Not applicable
5.22	No exclusion	Not applicable when evidence is provided by the health service organisation that they have had no incidents of pressure injuries over the preceding 12 months	No exclusion	Not applicable when evidence is provided that they have had no incidents of pressure injuries over the preceding 12 months	Not applicable
5.23	No exclusion	Not applicable when evidence is provided by the health service organisation that they have had no incidents of pressure injuries over the preceding 12 months	No exclusion	Not applicable when evidence is provided that they have had no incidents of pressure injuries over the preceding 12 months	Not applicable
5.24	No exclusion	Not applicable when evidence is provided by the health service organisation that they have had no incidents of falls over the preceding 12 months	No exclusion	a. No exclusion b. No exclusion c. Not applicable	a. No exclusion b. No exclusion c. Not applicable
5.25	No exclusion	Not applicable when evidence is provided by the health service organisation that they have had no incidents of falls over the preceding 12 months	No exclusion	No exclusion	No exclusion
5.26	No exclusion	Not applicable when evidence is provided by the health service organisation that they have had no incidents of falls over the preceding 12 months	No exclusion	No exclusion	Not applicable for community dental services
5.27	No exclusion	Not applicable for day procedure services that do not admit patients overnight.	No exclusion	Not applicable	Not applicable
5.28	No exclusion	Not applicable for day procedure services that do not prepare and distribute food and fluids to patients, such as chemo and dialysis units	No exclusion	Not applicable	Not applicable
5.29	No exclusion	A. Not applicable for day procedure services that do not provide care to patients who have cognitive impairment or are at risk of developing delirium during an episode of care b. Not applicable	No exclusion	A. Not applicable for services that do not provide care to patients who have cognitive impairment or are at risk of developing delirium during an episode of care b. Not applicable	Not applicable
5.30	No exclusion	Not applicable for day procedure services that do not admit patients who have cognitive impairment or are at risk of developing delirium during an episode of care	No exclusion	Not applicable for services that do not admit patients who have cognitive impairment or are at risk of developing delirium during an episode of care	No exclusion
5.31	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
5.32	No exclusion	Not applicable for day procedure services that do not admit patients who are at risk of self-harm or suicide during an episode of care	No exclusion	Not applicable for services that do not provide care to patients who are at risk of self-harm or suicide during an episode of care	Not applicable
5.33	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
5.34	No exclusion	Not applicable for day procedure services that do not admit patients who are at risk of aggressive or violent behaviour during an episode of care	No exclusion	No exclusion	No exclusion
5.35	No exclusion	Not applicable for day procedure services that do not use restrictive practices (restraint) during an episode of care	No exclusion	Not applicable for services that do not use restrictive practices (restraint) during an episode of care	Not applicable
5.36	No exclusion for gazetted health service organisations, not applicable for non-gazetted services	Not applicable	No exclusion for gazetted health service organisations, not applicable for non-gazetted services	No exclusion for gazetted health service organisations, not applicable for all other services	Not applicable

Communicating for Safety Standard

Action	Applicability to
Action	Hospitals	Day procedure services	Multi-purpose services	Community Healthcare Services	Public Dental services
6.01	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
6.02	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
6.03	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
6.04	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
6.05	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
6.06	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
6.07	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
6.08	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
6.09	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
6.10	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
6.11	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion

Blood Management Standard

Action	Applicability to
Action	Hospitals	Day procedure services	Multi-purpose services	Community Healthcare Services	Public Dental services
7.01	Not applicable for hospitals only where there is no use of blood or blood products	Not applicable for day procedure services that do not use blood and blood products.	Not applicable for multi-purpose services that do not use blood and blood products.	Not applicable for services that do not use blood and blood products.	Not applicable
7.02	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Not applicable
7.03	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Not applicable
7.04	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Not applicable
7.05	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Not applicable
7.06	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Not applicable
7.07	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Not applicable
7.08	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Not applicable
7.09	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Not applicable
7.10	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Depends on evidence provided in 7.1	Not applicable

Recognising and Responding to Acute Deterioration Standard

Action	Applicability to
Action	Hospitals	Day procedure services	Multi-purpose services	Community Healthcare Services	Public Dental services
8.01	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
8.02	No exclusion	No exclusion	No exclusion	No exclusion	Not applicable
8.03	No exclusion	No exclusion	No exclusion	No exclusion	Not applicable
8.04	No exclusion	No exclusion	No exclusion	Not Applicable for specialist settings where evidence is provided that a general observation chart is not used and alternative mechanisms are in place	Not Applicable for specialist settings where evidence is provided that a general observation chart is not normally used and alternative mechanisms are in place
8.05	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion Not applicable No exclusion No exclusion No exclusion
8.06	No exclusion	No exclusion	No exclusion	No exclusion	Not applicable
8.07	No exclusion	No exclusion	No exclusion	No exclusion	Not applicable
8.08	No exclusion	No exclusion	No exclusion	No exclusion	Not applicable
8.09	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
8.10	No exclusion	No exclusion	No exclusion	No exclusion	No exclusion
8.11	No exclusion	No exclusion	No exclusion	No exclusion	Not applicable
8.12	No exclusion	No exclusion	No exclusion	No exclusion	Not applicable
8.13	No exclusion	No exclusion	No exclusion	No exclusion	Not applicable

Multi-Purpose Services Aged Care Module

Action	Applicability to Multi-purpose services
A 1	No exclusion
A 2	No exclusion
A 3	No exclusion
A 4	No exclusion
A 5	No exclusion
A 6	No exclusion

Cosmetic Surgery Module

Actions	Applicability to Hospital and Day Surgery Services
1.03	No exclusion
1.04	No exclusion
1.07	Not applicable when evidence is provided that relevant clinical quality registries do not exist, or none are specified by the Medical Board of Australia.
2.05	No exclusion
2.06	No exclusion
2.07	No exclusion
2.10	No exclusion
2.12	No exclusion
5.07	No exclusion
5.09	No exclusion