Surgical services

1. The general acute hospital that provides surgical services shall have effective policies and procedures regarding surgical privileges, maintenance of the operating rooms, and evaluation of the surgical patient. a. Surgical services must be provided in a manner sufficient to meet the surgical needs of the patients. The surgical service must have a defined organization, must be integrated with other departments and services of the hospital, and must be governed by current written policies and procedures. b. Surgical services must be directed by a physician who is qualified by training and experience and approved by the medical staff and governing body. c. A roster of physicians, specifying the surgical privileges of each, must be maintained and available to staff in the surgical services area and in the files of the hospital administration. d. The operating rooms must be supervised by a qualified registered nurse. (1) A licensed practical nurse or a surgical technician may be used as "scrub nurse" under the supervision of the registered nurse. (2) A registered nurse may perform circulating duties in the operating room in accordance with applicable state law. Licensed practical nurses and surgical technicians may assist in circulating duties under the supervision of a registered nurse who is immediately available to respond to emergencies. e. The following equipment must be available for use in the surgical services area: call-in system, cardiac monitor, resuscitator, defibrillator, aspirator, tracheotomy tray, and such other instruments or equipment available for lifesaving measures. f. The surgical services area must be located so that traffic in and out can be and is controlled and there is no through traffic. g. All infections of clean surgical cases must be recorded and reported to administration and medical staff. A written procedure must be established for the investigation of such cases. h. The operating room register must be maintained as identified by hospital policy and procedure. i. There must be a complete history and physical examination, including any indicated laboratory and x-ray examination reports, in the medical record of every patient prior to surgery, except in life-threatening emergencies. If this has been transcribed, but not yet recorded in the patient's record, there must be a statement to that effect, an admission note identifying any abnormal findings, and the preoperative diagnosis in writing by the physician in the patient's medical record. j. An operative report describing techniques, findings, and tissue removed or altered must be dictated or written immediately after the surgery and signed by the surgeon. k. There must be a properly executed informed consent form consistent with hospital policies for operation in the patient's medical record prior to surgery, except in life-threatening emergencies. l. If outpatient surgical services are offered by a hospital, the quality of the services must be consistent with the inpatient surgical services in accordance with the complexity of the services. 2. If the primary care hospital provides surgical services, the hospital shall comply with surgical services requirements for general acute hospitals in this section. 3. If a specialized hospital provides surgical services, the specialized hospital is subject to the surgical services requirements for general acute hospitals in this section.