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; 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; 15. A physician discharges a patient from the designated area in subsection (2); and 16. A smoke evacuation system is used in each designated area to prevent exposure to surgical smoke as described in A.R.S. § 36-434.01.