N.J. Admin. Code § 8:43G-34.6

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

Section 8:43G-34.6 - Surgery patient services

(a) A patient identification system shall be implemented and patient identification shall be verified prior to any surgical procedure.

(b) There shall be a policy and procedure to verify the site and side of any and all surgical procedures. The procedure site and side shall be documented on the operative consent form.

(c) There shall be oral verification of the correct site and side of the surgical procedure in the operating room by a surgical team member in accordance with hospital policy.

(d) There shall be a system to ensure that surgical patients' personal effects are secured during surgery.

(e) The surgery services staff shall take precautions to prevent patient falls and injuries during transportation, transfer, and positioning through the use of side rails or restraint straps, and control devices on stretchers and operating tables.

(f) Each surgical patient shall have a medical record in accordance with the medical records policies of the hospital. The medical record shall be available to surgical suite personnel prior to surgery and shall include at least:

1. A written informed consent form signed by the patient or legal guardian or authorized person according to hospital policy that includes identification of the physician(s) performing the procedure prior to all procedures requiring informed consent;

2. A completed preoperative checklist;

3. A medical history and the results of a physical examination; and

4. Diagnostic tests results as determined by hospital policy.

(g) The surgical suite nursing staff shall make a preoperative note or notes for each surgical patient, which is part of the medical record and follows the patient to the patient care unit. The note shall describe intraoperative nursing care and patient reactions while in the operating suite.

(h) Operative reports shall be dictated or written in the medical record immediately after surgery.

(i) The completed operative report shall be reviewed for accuracy, signed and dated by the surgeon and filed in the medical record as soon as possible after surgery.

(j) There shall be a system in place for obtaining frozen section results on a timely basis.

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

N.J. Admin. Code § 8:43G-34.6

Amended by R.2003 d.57, effective 2/3/2003.
See: 34 New Jersey Register 232(a), 35 New Jersey Register 865(a).
Rewrote (a); added new (b) and (c); recodified existing (b) and (c) as (d) and (e); recodified and rewrote (d) and (e) as (f) and (g); recodified existing (f) through (i) as (h) through (k).