10A NCAC 13B .4605 POLICIES AND PROCEDURES
(a) The director of surgical services shall develop policies and procedures for surgical and anesthesia services which shall be available to the medical, surgical, anesthesia staff and nursing personnel.
(b) The facility shall require that policies on anesthesia procedures include the delineation of pre-anesthesia and post-anesthesia responsibilities.
(c) The facility shall require that the policies listed in this Paragraph are followed and that each surgical patient's record contain the following documentation:
(1) a complete history and physical documented in the record of every patient prior to surgery, including clinical indications for the surgical procedure;
(2) written evidence of informed consent, in the patient's record before surgery. If prior written consent was not obtained, the record shall contain a written explanation of why prior consent was not obtained;
(3) an evaluation of the patient and anesthesia planned, documented according to medical staff bylaws by an individual qualified to administer anesthesia services. Re-evaluation of the patient immediately prior to the induction of anesthesia shall be performed prior to surgery;
(4) an operative report describing techniques, findings, tissue removed or altered, and pre and post-surgical diagnosis. This report must be written or dictated following surgery and signed by the surgeon in compliance with medical staff rules;
(5) an intraoperative anesthesia record including the dosage of all drugs and agents used, the duration of anesthesia, and the type and amount of all fluids or blood and blood products administered shall be documented;
(6) evaluation and documentation of the postoperative status of the patient on admission to and discharge from the post-anesthesia recovery area.
(d) The director of anesthesia services shall establish criteria for discharge and facility management shall require that a physician or CRNA with appropriate clinical privileges be responsible for the decision to discharge a patient from a post-anesthesia recovery area.
(e) The facility shall establish regulations governing visitors and traffic control.
History Note: Authority G.S. 131E-79;
Eff. January 1, 1996;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 22, 2017.