Written policies and procedures shall be
developed and maintained by the person responsible for the service in
consultation with other appropriate health professionals and administration.
Policies shall be approved by the governing body. Procedures shall be approved
by the administration and medical staff where such is appropriate. The policies
and procedures shall include provision for at least:
(1) Preanesthesia evaluation of the patient
by an individual qualified to administer anesthesia as a licensed practitioner
in accordance with his or her scope of licensure. Persons providing
preanesthesia evaluations shall appropriately document pertinent information
relative to the choice of anesthesia and the surgical or obstetrical procedure
(2) Review of the
patient's condition immediately prior to induction of anesthesia.
(3) Safety of the patient during the
(4) Recording of
all events taking place during the induction of, maintenance of and emergence
from anesthesia, including the amount and duration of all anesthetic agents,
other drugs, intravenous fluids and blood or blood fractions.
(5) Recording of postanesthetic visits that
include at least one note describing the presence or absence of complications
related to anesthesia.
(b) The responsibility and the accountability
of the anesthesia service to the medical staff and administration shall be
(c) Rules for the safe use
of nonflammable and flammable anesthetic agents which conform with the rules of
the State Fire Marshal and Section 70849 shall be adopted.
(d) Periodically, an appropriate committee of
the medical staff shall evaluate the service provided and make appropriate
recommendations to the executive committee of the medical staff and
requirements in this section do not apply to special hospitals unless the
special hospital provides this service.