Current through Register Vol. 42, No. 11, August 30, 2024
(1) If
the hospital provides surgical services, the services shall be well organized
and provided in accordance with acceptable standards of practice. If outpatient
surgical services are offered the services shall be consistent in quality with
inpatient care in accordance with the complexity of services offered.
(2) Organization and staffing. The
organization of the surgical services shall be appropriate to the scope of the
services offered.
(a) The operating rooms
shall be supervised by an experienced registered nurse or a doctor of medicine
or osteopathy.
(b) Licensed
practical nurses (LPNs) and surgical technologists (operating room technicians)
may serve as "scrub nurses" or "scrub techs" under the supervision of a
registered nurse.
(c) Qualified
registered nurses may perform circulating duties in the operating room. In
accordance with state laws and approved medical staff policies and procedures,
LPNs may assist in circulatory duties under the supervision of a qualified
registered nurse who is immediately available to respond to emergencies.
Registered nurses may also serve as registered nurse first assistants
(RNFAs).
(d) Surgical privileges
shall be delineated for all practitioners performing surgery in accordance with
the competencies of each practitioner. The surgical service shall maintain a
roster of practitioners specifying the surgical privileges of each
practitioner.
(3)
Delivery of service. Surgical services shall be consistent with needs and
resources. Policies governing surgical care shall be designed to assure the
achievement and maintenance of high standards of medical practice and patient
care.
(a) Prior to surgery or a procedure
requiring anesthesia services and except in the case of emergencies:
1. A medical history and physical examination
shall be completed and documented no more than 30 days before or 24 hours after
admission or registration.
2. An
updated examination of the patient, including any changes in the patient's
condition, shall be completed and documented within 24 hours after admission or
registration when the medical history and physical examination are completed
within 30 days before admission or registration.
(b) A properly executed informed consent form
for the operation shall be in the patient's chart before surgery, except in
emergencies.
(c) The following
equipment shall be available to the operating room suites: call-in-system,
cardiac monitor, resuscitator, defibrillator, aspirator, and tracheotomy
set.
(d) There shall be adequate
provisions for immediate post-operative care.
(e) The operating room register shall be
complete and up-to-date.
(f) An
operative report describing techniques, findings, and tissues removed or
altered shall be written or dictated immediately following surgery and signed
by the surgeon
Author: W.T. Geary, Jr., M.D., Carter
Sims
Statutory Authority:
Code of Ala.
1975, §§
22-21-20, et
seq.
