PURPOSE: This rule specifies the requirements for surgical services in a hospital.
- (1) Surgical services, if provided, shall be under the medical direction of a qualified physician member of the medical staff and appointed by the governing body. This physician shall be responsible for implementing rules of the medical staff governing the quality and scope of surgical services.
- (2) Approved written policies and procedures shall define and describe the scope and con- 19 CSR 30-20
duct of surgical services. These shall be reviewed annually and revised as necessary.
- (3) The surgical suite shall be supervised by a qualified registered professional nurse with relevant education, experience and demonstrated current competency. This supervisor shall have the authority to implement hospital policies and procedures for the surgical suite and shall have the responsibility for evaluating all nursing personnel assigned to the surgical suite.
- (4) A qualified registered professional nurse shall be assigned circulating duties for surgical procedures performed.
- (5) Accepted standards of patient care, sterility and aseptic techniques shall be maintained.
- (6) Prior to surgery, the patient’s medical record shall contain evidence that the patient has been advised as to the surgical procedure(s) contemplated, the type of anesthesia to be administered and the risks involved with each. Evidence that informed consent has been given shall become a part of the patient’s medical record.
- (7) An operating room record documenting the patient care provided shall become a part of the patient’s medical record. The record shall contain at least the name of the patient, the patient’s hospital number, the name of the surgeon, name of surgical procedure(s), the date, time surgery began and ended, names and titles of persons assisting with the procedure and the verification of countable materials.
- (8) There shall be a mechanism for the review and evaluation on a regular basis of the quality and appropriateness of surgical services.
AUTHORITY: sections 192.006 and 197.080, RSMo 2000 and 197.154, RSMo Supp. 2007.* This rule previously filed as 19 CSR 30-20.021(4)(L). Original rule filed June 27, 2007, effective Feb. 29, 2008.
*Original authority: 192.006, RSMo 1993, amended 1995; 197.080, RSMo 1953, amended 1993, 1995; and 197.154, RSMo 2004.