PURPOSE: This rule specifies the requirements for surgical services in a hospital.

1. (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. (2) Approved written policies and procedures shall define and describe the scope and conduct of surgical services. These shall be kept current per hospital policy and are readily available to staff.
3. (3) The surgical suite shall be directed by a qualified registered professional nurse with relevant education and experience. This director 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. (4) A qualified registered professional nurse with relevant education, experience, and competency shall be assigned circulating duties for surgical procedures performed.
5. (5) Accepted standards of patient care, sterility, and aseptic techniques shall be maintained. SENIOR SERVICES
6. (6) Prior to surgery, except in the case of emergencies, the patient’s medical record shall contain evidence of informed consent.
7. (7) A medical history and physical examination must be completed and documented no more than thirty (30) days before or twentyfour (24) hours after admission or registration but prior to surgery or a procedure requiring anesthesia services, except in the case of emergencies. An updated examination of the patient, including any changes in the patient’s condition, must be completed and documented within twenty-four (24) hours after admission or registration when the medical history and physical examination are completed within thirty (30) days before admission or registration, except in the case of emergencies. The medical history and physical examination must be placed in the patient’s medical record within twenty-four
8. (24) hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, except in the case of emergencies.
9. (8) 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 and hospital identification number of the patient; date and times of the surgery; name(s) of the surgeon(s) and assistants or other practitioners who performed surgical tasks; pre-operative and post-operative diagnosis; name of the specific surgical procedure(s) performed; type of anesthesia administered; any complications; description of techniques, findings, and tissues removed or altered; any prosthetic devices, grafts, tissues, transplants, or devices implanted; and the verification of countable materials.
10. (9) There shall be a process for the review and evaluation on a regular basis of the quality and appropriateness of surgical services.

AUTHORITY: section 192.006, RSMo 2000, and sections 197.080 and 197.154, RSMo Supp. 2013.* This rule previously filed as 19 CSR 30-20.021(4)(L). Original rule filed June 27, 2007, effective Feb. 29, 2008. Amended: Filed Dec. 31, 2013, effective Aug. 30, 2014.

*Original authority: 192.006, RSMo 1993, amended 1995; 197.080, RSMo 1953, amended 1993, 1995; and 197.154, RSMo 2004.