Section 7.12.120. Surgical service.

	(a)  A registered nurse with knowledge and experience in surgical techniques and procedures must have supervisory responsibility for the surgical suite and, in cooperation with the surgical committee of the medical staff, if the hospital has one, and the infection control committee, establish policies and procedures for the surgical service.  
	(b)  A list of which surgical privileges are held by individual members of the medical staff must be available in the surgical suite for reference by the supervisor.  
	(c)  Before a surgical procedure begins, either the surgeon or the person responsible for administering anesthesia, and the surgical supervisor or his designee shall confirm the patient's identity and the site and side of the body to be operated upon, and ascertain that the patient's medical record contains a complete history and physical examination for the current admission, appropriate current screening tests based on the needs of the patient, and signed informed consent for the surgery. In the case of an emergency, the history and physical examination requirements are waived.  
	(d)  A daily register of operations must be maintained.  
	(e)  Emergency equipment, including thoracotomy and tracheotomy sets and a defibrillator, must be available in the surgical suite area when surgery is being performed.  
	(f)  As determined by medical staff under 7 AAC 12.110(c)(9), anatomical parts, tissues, and foreign objects which have been removed by operation, must be referred to a pathologist designated by the hospital. A report of the pathologist's findings must be filed in the patient's medical record.  
	(g)  A registered nurse must be present to circulate for each surgical procedure.  
	(h)  A rural primary care hospital or a critical access hospital must meet the standards set out in 7 AAC 12.130 if its governing body elects to offer surgical service.  

Authorities

18.20.010;18.20.060

Notes

Reference

7 AAC 12.355

Authority

AS 18.20.010 AS 18.20.060

History

Eff. 11/19/83, Register 88; am 5/4/97, Register 142; am 9/1/2000, Register 155