Awareness : Newsletter Articles

Condition of Participation: Surgical Services

Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. Prior to surgery or a procedure requiring anesthesia services and except in the case of emergencies:

  • A medical history and physical examination must be completed and documented no more than 30 days before or 24 hours after admission or registration.
  • An updated examination of the patient, including any changes in the patient’s condition, must 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.
  • A properly executed informed consent form for the operation must be in the patient’s chart before surgery, except in emergencies.
  • The following equipment must be available to the operating room suites: call-in-system, cardiac monitor, resuscitator, defibrillator, aspirator, and tracheotomy set.
  • There must be adequate provisions for immediate post-operative care.
  • The operating room register must be complete and up-to-date.
  • An operative report describing techniques, findings, and tissues removed or altered must be written or dictated immediately following surgery and signed by the surgeon.