Current through Register Vol. 43, No. 39, September 26, 2024
(a) General
provisions. Surgical services shall be provided in a manner sufficient to meet
the medical needs of the patients.
(b) Personnel.
(1) The director of surgical services shall
be a qualified member of the medical staff with appropriate surgical and
administrative experience.
(2) A
roster of medical staff members, with a delineation of the surgical privileges
granted to each, shall be maintained in the surgical suite and available to the
surgical nurse supervisor.
(3)
Surgical suite nursing services shall be under the direction and supervision of
a registered nurse who is qualified by training and experience in operating
room management and techniques. At least one registered nurse shall be on duty
in the recovery room whenever the room is occupied.
(c) Facilities.
(1) Admission of patients, personnel and
visitors to the surgical suite shall be controlled in accordance with written
policies.
(2) The following
equipment shall be immediately available to the surgical suite:
(A) A call system;
(B) a cardiac monitor;
(C) a resuscitator;
(D) a defibrillator;
(E) an aspirator;
(F) a thoracotomy set; and
(G) a tracheotomy set.
(3) Facilities for blood transfusions shall
be available at all times.
(d) Policies. The medical staff shall develop
written policies and procedures governing surgical services. These shall
include:
(1) Appointment procedures which
fairly evaluate the quality and competence of each surgeon seeking appointment
to the surgical staff;
(2)
reappointment procedures which provide for the periodic reappraisal of the
qualifications and competence of each surgeon;
(3) criteria to determine the circumstances
which require the presence of an assistant during surgery and to determine
whether the assistant should be a physician or professional or nonprofessional
personnel;
(4) procedures
requiring that preoperative and postoperative medical records are completed in
a timely and accurate manner. An accurate and complete description of findings
and techniques of operation shall be made within 24 hours after operation by
the surgeon who performed the operation; and
(5) procedures requiring that all tissues
removed at surgery be examined by a physician whose report shall become a part
of the patient's medical record.
(e) Operating room register. An operating
room register shall be provided and maintained on a current basis. This
register shall contain the date of the operation, the name and number of the
patient, the names of surgeons and surgical assistants, the name of the
anesthetist, the type of anesthesia given, preoperative and postoperative
diagnosis, the type of surgical procedure and the presence or absence of
complications in surgery.
