New Jersey Administrative Code
Title 8 - HEALTH
Chapter 43A - MANUAL OF STANDARDS FOR LICENSING OF AMBULATORY CARE FACILITIES
Subchapter 12 - SURGICAL AND ANESTHESIA SERVICES
Section 8:43A-12.6 - Surgical policies and procedures

1. Delineation of the surgical and anesthesia services which may be performed in the facility;

2. Delineation of the responsibilities of medical staff members in providing care to patients;

3. Designation of a time frame and of persons responsible for completing a medical history, physical examination, and laboratory tests prior to surgery;

4. Policies and procedures regarding preanesthesia evaluation, patient preparation, and intraoperative management;

5. Policies and procedures to ensure that every patient is examined by a practitioner immediately prior to surgery;

6. A registered professional nurse shall be assigned to circulating nurse duties in each room where surgery is being performed;

7. Policies and procedures for use of analgesia and anesthesia, including types which may be used for each procedure, safety regulations, and responsibilities and qualifications of persons who administer anesthesia and monitor patients;

8. Policies and procedures for the preoperative and postoperative recording of vital signs (blood pressure, temperature, pulse and respiration rate);

9. Policies for reporting of morbidity and mortality in accordance with 8:43A-12.7(b);

10. Policies and procedures for monitoring of patients in any special procedure room or other location where patients receive anesthesia;

11. Policies and procedures for postoperative observation and care required for each type of procedure;

12. Methods to ensure that gross and microscopic tissue removed surgically or by any other procedure, including termination of pregnancy in accordance with the regulations of the New Jersey State Board of Medical Examiners, 13:35-4.2, is examined by a pathologist and a report of the findings is documented in the patient's medical record;

13. Policies for discharge criteria from the facility;

14. Requirements for written documentation of surgical procedures performed, including at least a description of the findings, procedures used, specimens removed, patient's condition, any unusual events occurring during the procedure, postoperative diagnosis, and names of the surgeon and assistants. This operative note shall be written or dictated immediately following the procedure by the person performing the surgery and incorporated into the patient's medical record;

15. Policies and procedures for the provision of written instructions to the patient (multilingual, if indicated) on preoperative and postoperative care, including, but not limited to, restrictions on food and beverages before surgery and procedures for obtaining help in the event of surgical wound infection or other postoperative problems;

16. Policies and procedures regarding infection prevention and control shall be reviewed at least every three years and revised more frequently if needed, including, but not limited to, the following:

17. All surgical staff shall comply with the universal precautions set forth in the Centers for Disease Control and Prevention Guideline for Handwashing and Hospital Environmental Control. (Centers for Disease Control and Prevention Guideline for Prevention of Surgical Site Infections (1999) (Infection Control and Hospital Epidemiology 1999; 20:247-278), incorporated herein by reference, as amended and supplemented. That publication may be obtained by telephoning the Centers for Disease Control and Prevention at (800) 311-3435.)