§ 70223. Surgical Service General Requirements.

(a) Hospitals shall maintain at least the number of operating rooms in ratio to licensed bed capacity as follows:

Licensed Bed Capacity	Number of Operating Rooms
Less than 25	One
25 to 99	Two
100 or more	Three

For each additional 100 beds or major fractions thereof, at least one additional operating room shall be maintained, unless approved to the contrary by the Department.

(1) Required operating rooms are in addition to special operating rooms, cystoscopy rooms and fracture rooms which are provided by the hospital.

(2) Beds in a distinct part skilled nursing service, intermediate care service or psychiatric unit shall be excluded from calculating the number of operating rooms required.

(b) A committee of the medical staff shall be assigned responsibility for:

(1) Recommending to the governing body the delineation of surgical privileges for individual members of the medical staff. A current list of such privileges shall be kept in the files of the operating room supervisor.

(2) Development, maintenance and implementation of written policies and procedures in consultation with other appropriate health professionals and administration. Policies shall be approved by the governing body. Procedures shall be approved by the administration and medical staff where such is appropriate.

(3) Determining what emergency equipment and supplies shall be available in the surgery suite.

(4) Determining which operative procedures require an assistant surgeon or assistants to the surgeon.

(c) The responsibility and the accountability of the surgical service to the medical staff and administration shall be defined.

(d) Prior to commencing surgery the person responsible for administering anesthesia, or the surgeon if a general anesthetic is not to be administered, shall verify the patient's identity, the site and side of the body to be operated on, and ascertain that a record of the following appears in the patient's medical record:

(1) An interval medical history and physical examination performed and recorded within the previous 24 hours.

(2) Appropriate screening tests, based on the needs of the patient, accomplished and recorded within 72 hours prior to surgery.

(3) An informed consent, in writing, for the contemplated surgical procedure.

(e) The requirements of (d), above, do not preclude rendering emergency medical or surgical care to a patient in dire circumstances.

(f) A register of operations shall be maintained including the following information for each surgical procedure performed:

(1) Name, age, sex and hospital admitting number of the patient.

(2) Date and time of the operation and the operating room number .

(3) Preoperative and postoperative diagnosis.

(4) Name of surgeon, assistants, anesthetists and scrub and circulating assistant.

(5) Surgical procedure performed and anesthetic agent used.

(6) Complications, if any, during the operation.

(g) All anatomical parts, tissues and foreign objects removed by operation shall be delivered to a pathologist designated by the hospital and a report of his findings shall be filed in the patient's medical record.

(h) Periodically, an appropriate committee of the medical staff shall evaluate the services provided and make appropriate recommendations to the executive committee of the medical staff and administration.

(i) The requirements in this section do not apply to special hospitals unless the special hospital provides this service.

HISTORY

1. New subsection (i) filed 7-28-78; effective thirtieth day thereafter (Register 78, No. 30).