12VAC5-410-420: Surgical service

A. The surgical department/service shall have a defined organization and shall be governed by written policies and procedures.

B. The surgical department/service shall be under the medical supervision of a physician who meets the requirements of the medical staff bylaws.

C. The operating suite shall be:

1. Under the supervision of a registered professional nurse.

2. Designed to include operating and recovery rooms, proper scrubbing, sterilizing and dressing room facilities, and storage for anesthetic agents and shall be equipped as required by the scope and complexity of the services.

3. Provided with prominently posted safety policies and procedures.

D. A roster of current surgical privileges of every surgical staff member shall be maintained on file in the operating suite.

E. An operating room register shall be maintained, which shall include, as a minimum:

1. Patient's name and hospital number;

2. Pre-operative and post-operative diagnosis;

3. Complications, if any;

4. Name of surgeon, first assistant, anesthesiologist or anesthetist, scrub nurse, and circulating nurse;

5. Operation performed; and

6. Type of anesthesia.

F. Every hospital where surgical procedures are performed shall adopt a policy requiring the use of a smoke evacuation system for all planned surgical procedures that are likely to generate surgical smoke.

G. Policies and procedures governing infection control and reporting techniques shall be established in accordance with 12VAC5-410-490.

H. The patient's medical chart shall be available in the surgical suite at time of surgery and shall contain no less than the following information:

1. A medical history and physical examination;

2. Evidence of appropriate informed consent; and

3. A pre-operative diagnosis.

I. An accurate and complete description of operative procedure shall be recorded by the operating surgeon within 48 hours following completion of surgery and made part of the patient's clinical record.