N.J. Admin. Code § 8:43G-32.5

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

Section 8:43G-32.5 - Same-day surgery patient services

(a) There shall be documentation of perioperative patient education.

(b) There shall be a system to ensure checking of each patient's preoperative record for completeness before the procedure begins.

(c) Physician orders, specific for each patient, shall govern the postoperative care of each patient.

(d) After the surgical procedure and before discharge, the patient and/or significant other shall receive written and oral instructions on self-care, follow-up, signs and symptoms to be reported to the surgeon, and how to report signs and symptoms.

(e) The medical record for same-day surgery patients shall include at least:

1. The patient's written informed consent;

2. A preoperative note by the physician, dentist, or podiatrist, which includes the surgical plan;

3. A preoperative anesthesia note by the anesthesiologist, if applicable;

4. Documentation of the history and physical examination performed by a physician or clinical practitioner within 30 days, including all updates and assessments as set forth at 8:43G-16.6(b), prior to the procedure;

5. Preadmission testing results;

6. A preoperative nursing assessment;

7. A perioperative nurses' note that describes the patient's condition during the procedure;

8. A medication record reflecting the drug given, date, time, dosage, route of administration, and signature and status of individual administering the drug;

9. Any physician orders;

10. The surgeon's postoperative note on the procedure;

11. The surgeon's discharge note, written prior to discharge from the hospital, which describes the disposition of the patient and discharge instructions; and

12. Nurses' notes that describe the patient's postoperative progress.

N.J. Admin. Code § 8:43G-32.5

Amended by R.1992 d.72, effective 2/18/1992.
See: 23 N.J.R. 2590(a), 24 N.J.R. 590(a).
Documentation requirements added.
Amended by R.1999 d.436, effective 12/20/1999.
See: 31 N.J.R. 367(a), 31 N.J.R. 614(a), 31 N.J.R. 4293(c).
Rewrote (e)4.
Amended by R.2005 d.279, effective 9/6/2005.
See: 37 N.J.R. 709(a), 37 N.J.R. 3365(a).
Rewrote (e)4.