Section R9-10-215. Surgical Services

An administrator of a general hospital shall ensure that:

1.        There is an organized service that provides surgical ser- vices 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 privi- leges to perform surgical procedures in the surgical ser- vices area;

5.        Postoperative orders are documented in the patient’s medical record;

6.        There is a chronological log of surgical procedures per- formed 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 pro- cedure;

7.        The chronological log required in subsection (A)(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 proce- dures that may be performed in areas other than the surgi- cal services area;

9.        The hospital has the medical staff members, personnel members, and equipment to provide the surgical proce- dures 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 pro- cedure;

11.     Except in an emergency, a medical staff member or a sur- geon performs a medical history and physical examina- tion within 30 calendar days before performing a surgical procedure on a patient;

12.     Except in an emergency, a medical staff member or a sur- geon enters an interval note in the patient's medical record before performing a surgical procedure;

13.     Except in an emergency, 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 (A)(11) and an interval note as required in subsection (A)(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 proce- dures; and

14.     Within 24 hours after a surgical procedure on a patient is completed.

Historical Note

Former Section R9-10-215 renumbered as R9-10-315 as an emergency effective February 22, 1979, new Section R9-10-215 adopted effective February 23, 1979 (Supp. 79-1). Amended subsection (D) effective August 31, 1988 (Supp. 88-3). Section repealed; new Section made by final rulemaking at 8 A.A.R. 2785, effective October 1, 2002 (Supp. 02-2). Section R9-10-215 renumbered to R9-10-216; new Section R9-10-215 renumbered from R9-10-214 and amended by exempt rulemaking at 19

A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). Amended by exempt rulemaking at 20 A.A.R. 1409, pur- suant to Laws 2013, Ch. 10, § 13; effective July 1, 2014

(Supp. 14-2).