Ala. Admin. Code r. 420-5-7-.17

Current through Register Vol. 43, No. 1, October 31, 2024

Section 420-5-7-.17 - Surgical Services

(1) If the hospital provides surgical services, the services shall be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services shall be consistent in quality with inpatient care in accordance with the complexity of services offered.

(2) Organization and staffing. The organization of the surgical services shall be appropriate to the scope of the services offered.

(a) The operating rooms shall be supervised by an experienced registered nurse or a doctor of medicine or osteopathy.

(b) Licensed practical nurses (LPNs) and surgical technologists (operating room technicians) may serve as "scrub nurses" or "scrub techs" under the supervision of a registered nurse.

(c) Qualified registered nurses may perform circulating duties in the operating room. In accordance with state laws and approved medical staff policies and procedures, LPNs may assist in circulatory duties under the supervision of a qualified registered nurse who is immediately available to respond to emergencies. Registered nurses may also serve as registered nurse first assistants (RNFAs).

(d) Surgical privileges shall be delineated for all practitioners performing surgery in accordance with the competencies of each practitioner. The surgical service shall maintain a roster of practitioners specifying the surgical privileges of each practitioner.

(3) Delivery of service. Surgical services shall be consistent with needs and resources. Policies governing surgical care shall be designed to assure the achievement and maintenance of high standards of medical practice and patient care.

(a) Prior to surgery or a procedure requiring anesthesia services and except in the case of emergencies:

1. A medical history and physical examination shall be completed and documented no more than 30 days before or 24 hours after admission or registration.

2. An updated examination of the patient, including any changes in the patient's condition, shall be completed and documented within 24 hours after admission or registration when the medical history and physical examination are completed within 30 days before admission or registration.

(b) A properly executed informed consent form for the operation shall be in the patient's chart before surgery, except in emergencies.

(c) The following equipment shall be available to the operating room suites: call-in-system, cardiac monitor, resuscitator, defibrillator, aspirator, and tracheotomy set.

(d) There shall be adequate provisions for immediate post-operative care.

(e) The operating room register shall be complete and up-to-date.

(f) An operative report describing techniques, findings, and tissues removed or altered shall be written or dictated immediately following surgery and signed by the surgeon

Ala. Admin. Code r. 420-5-7-.17

Filed September 1, 1982. Amended: Filed March 20, 1992. Repealed and New Rule: Filed November 18, 1994; effective December 23, 1994. Repealed and New Rule: Filed August 24, 2012; effective September 28, 2012.

Author: W.T. Geary, Jr., M.D., Carter Sims

Statutory Authority:Code of Ala. 1975, §§ 22-21-20, et seq.