(a)

1. (1) There shall be policies and procedures specific to ambulatory surgery services.
2. (2) Policies and procedures for the department shall have evidence of ongoing review and/or revision.

3. (3) The first page of each manual shall have the:

   1. (A) Annual review date; and
   2. (B) Signature of the department supervisor and/or person or persons conducting the review.

(b)

1. (1) Policies and procedures shall include:

   1. (A) Scheduling of patients for surgery;
   2. (B) Admission and discharge criteria;
   3. (C) Perioperative patient care;
   4. (D) Operative and special consents;
   5. (E)

(i) Obtaining a documented history and physical on the patient’s medical record prior to the procedure.

1. (ii) Refer to Health Information Services, 20 CAR § 41-113;

   1. (F) Preoperative assessment procedures required by the medical staff; and
   2. (G) Medication accountability.

2. (2) Refer to:

   1. (A) 20 CAR § 40-110, patient care service;
   2. (B) 20 CAR § 40-111, medications; and

   3. (C) 20 CAR § 40-115, pharmacy.

      1. (c) A physician shall order the discharge of the patient from the facility.
      2. (d) For additional requirements, refer to:
3. (1) 20 CAR § 40-110, patient care service;
4. (2) 20 CAR § 40-125, specialized services — surgical services; and
5. (3) 20 CAR § 40-126, specialized services — postanesthesia care unit.