Section 410IAC15-1.6-8. Surgical services

 

                (a) If the hospital provides inpatient or ambulatory surgical services, the services shall meet the needs of the patients served, within the scope of the service offered, and in accordance with acceptable standards of practice and safety.

                (b) The organization of the surgical services shall be appropriate, according to the scope of the services offered, as follows:

(1) The surgical service shall be under the direction of a physician qualified by experience and training.

(2) An experienced registered nurse shall supervise all nursing personnel in surgical services and postanesthesia care units (PACU), as follows:

(A) Licensed practical nurses, operating room technicians (ORTs), obstetrical technicians (OB Techs), and surgical technologists may serve as scrub personnel under the supervision of a qualified registered nurse.

(B) Circulating duties in the operating room shall be performed by a qualified registered nurse. Licensed practical nurses and surgical technologists may assist in circulating duties under the supervision of a qualified registered nurse who is immediately available to respond to emergencies, in accordance with applicable state law and approved written medical staff policies and procedures.

                (c) Surgical services shall have policies governing surgical care designed to assure the achievement and maintenance of standards of medical practice and patient care, as follows:

(1) A mechanism shall be maintained which specifies the delineated surgical privileges of each practitioner.

(2) There shall be a history and physical workup in the chart of every patient prior to surgery, except in emergencies. If this has been dictated, but not yet recorded in the patient's chart, there shall be a statement to that effect and an admission note in the chart by the admitting physician, which includes vital signs, allergies, and appropriate data.

(3) A properly executed informed consent form for the operation shall be in the patient's chart before surgery, except in extreme emergencies.

(4) The following equipment shall be available to the operating room suites and PACU:

(A) Cardiac monitor.

(B) Resuscitation equipment.

(C) Defibrillator.

(D) Aspirator.

(E) Oximeter.

(F) Tracheotomy set.

(5) There shall be adequate provision for immediate postoperative care.

(6) The operating room register shall be complete and up-to-date.

(7) An operative report describing techniques, findings, and tissue removed or altered shall be written or dictated immediately following surgery and authenticated by the surgeon.

(8) A list of tissues excluded from microscopic examination, if applicable, shall be maintained in surgery services.

(9) There shall be no explosive anesthetic agents, flammable, or potentially flammable, liquids or agents stored or used in the surgical services area.

(Indiana State Department of Health; 410 IAC 15-1.6-8; filed Dec 21, 1994, 9:40 a.m.: 18 IR 1279; readopted filed Jul 11, 2001, 2:23 p.m.: 24 IR 4234; readopted filed May 22, 2007, 1:44 p.m.: 20070613-IR-410070141RFA; readopted filed Jul 14, 2011, 11:42 a.m.: 20110810-IR-410110253RFA)