N.J. Admin. Code § 13:35-4A.4

Current through Register Vol. 56, No. 21, November 4, 2024

Section 13:35-4A.4 - Policies and procedures requirements

(a) Practitioners who perform surgery or special procedures (other than minor procedures), and physicians who administer or supervise the administration or monitoring of anesthesia services in an office shall establish written policies and procedures concerning the following:

1. The specific surgical or special procedures which may be performed in the office;

2. The specific anesthesia services which may be performed in the office;

3. The responsibilities of the health care personnel providing services to patients in the office;

4. The infection control practices to be followed, including lawful disposal of hazardous waste;

5. The procedures to be followed in the event that a patient experiences a complication;

6. The procedures to be followed if the patient requires transport for emergency services, including the identity and telephone numbers of the ambulance service if one is to be utilized and the hospital to which the patient is to be transported, and the functions to be undertaken by health care personnel until a transfer of the patient is completed;

7. The procedures to be followed in the event that a surgery or special procedure needs to be terminated because of an equipment malfunction or other complication;

8. The procedures to be followed while a patient is recovering in the office;

9. The objective criteria for discharging patients; and

10. The procedures to be followed to review records, and to ensure follow-up on complications and outcomes.

(b) The written policies and procedures shall also contain the identity of the specific practitioners within the office who are responsible for ensuring that:

1. All healthcare personnel providing services to patients possess the qualifications required by this subchapter and are currently licensed, registered or certified, as applicable;

2. All equipment and instruments utilized in the performance of surgery or special procedures are maintained in proper working order and in accordance with such sterilization techniques as are required for safe medical practice;

3. All equipment and safety systems utilized in the administration and monitoring of anesthesia as required by 13:35-4A.14 are maintained in proper working order;

4. All emergency equipment and supplies as required by 13:35-4A.13 are available and are not out-dated; and

5. All medical records are audited on at least an annual basis to assess quality of care and complications.

(c) The written policies and procedures are to be reviewed annually and revised as needed with the person conducting the review or making the revision recording the date thereof.

(d) Written policies and procedures shall be presented to the Board upon request.

N.J. Admin. Code § 13:35-4A.4

Amended by 53 N.J.R. 2013(a), effective 12/6/2021