Ariz. Admin. Code § R9-10-215 - Surgical Services
An administrator of a general hospital shall ensure that:
1. There is an organized service
that provides surgical services under the direction of a medical staff
member;
2. There is a designated
area for providing surgical services as an organized service;
3. The area of the hospital designated for
surgical services is managed by a registered nurse or a physician;
4. Documentation is available in the surgical
services area that specifies each medical staff member's clinical privileges to
perform surgical procedures in the surgical services area;
5. Postoperative orders are documented in the
patient's medical record;
6. There
is a chronological log of surgical procedures performed in the surgical
services area that contains:
a. The date of
the surgical procedure,
b. The
patient's name,
c. The type of
surgical procedure,
d. The time in
and time out of the operating room,
e. The name and title of each individual
performing or assisting in the surgical procedure,
f. The type of anesthesia used,
g. An identification of the operating room
used, and
h. The disposition of the
patient after the surgical procedure;
7. The chronological log required in
subsection (6) is maintained in the surgical services area for at least 12
months after the date of the surgical procedure and then maintained by the
hospital for an additional 12 months;
8. The medical staff designate in writing the
surgical procedures that may be performed in areas other than the surgical
services area;
9. The hospital has
the medical staff members, personnel members, and equipment to provide the
surgical procedures offered in the surgical services area;
10. A patient and the surgical procedure to
be performed on the patient are identified before initiating the surgical
procedure;
11. Except in an
emergency, a medical staff member or a surgeon performs a medical history and
physical examination within 30 calendar days before performing a surgical
procedure on a patient;
12. Except
as provided in subsection (14), a medical staff member or a surgeon enters an
interval note in the patient's medical record before performing a surgical
procedure;
13. Except as provided
in subsection (14), the following are documented in a patient's medical record
before a surgical procedure:
a. A preoperative
diagnosis;
b. Each diagnostic test
performed in the hospital;
c. A
medical history and physical examination as required in subsection (11) and an
interval note as required in subsection (12);
d. A consent or refusal for blood or blood
products signed by the patient or the patient's representative, if applicable;
and
e. Informed consent according
to policies and procedures; and
14. In an emergency, the documentation
required in subsections (12) and (13) is completed within 24 hours after a
surgical procedure on a patient is completed.
Notes
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No prior version found.