Compilation of Rules and Regulations of the State of Georgia › Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH › Chapter 111-8 - HEALTHCARE FACILITY REGULATION › Subject 111-8-40 - RULES AND REGULATIONS FOR HOSPITALS › Rule 111-8-40-.28 - Surgical Services

Current through Rules and Regulations filed through June 27, 2024
If the hospital provides surgical services, the services
				  shall be provided in a manner which protects the health and safety of the
				  patients and follows current accepted standards of medical and surgical
				  practice. Personnel, equipment, policies and procedures, and the number of
				  operating rooms shall be appropriate for the scope of services offered.
(a)
Organization of Surgical Services.
The hospital shall have an organizational plan which defines lines of
				authority, responsibility, and accountability within all operating room areas
				where surgical procedures are performed.
1.
				There shall be a current roster of surgical privileges granted each medical
				staff member available to nursing and scheduling staff in the surgical services
				area(s).
2. The hospital shall have
				bylaws, rules, or policies and procedures developed by the medical staff which
				require that within twenty-four (24) hours prior to surgery either a history
				and physical examination or an update of a previous history and physical is
				completed for every surgical patient. Where an update is used, the previous
				history and physical examination must not have occurred more than thirty (30)
				days prior to surgery.
3. Roles,
				responsibilities, and qualifications for any non-physician first and second
				assistants participating in surgery shall be defined by the hospital medical
				staff, including any limitations to their roles in patient care.
4.
Chief(s) of Surgery.
Physician member(s) of the medical staff, who have been appropriately
				trained in the provision of surgical services, shall be designated by the
				medical staff to direct the hospital's surgical services, and shall be
				responsible for all clinical aspects of organization and delivery of the
				particular surgical services including the evaluation of the effectiveness of
				the services in coordination with the hospital's quality management program.
(i) The chief(s) of surgery shall be
				responsible for implementation of hospital policy related to medical staff
				utilizing the surgical suite.
(ii)
				In conjunction with the hospital's medical staff, the chief(s) of surgery shall
				implement procedures requiring an operative report for each surgery performed.
(I) The operative report shall describe
				techniques, findings, complications, tissues removed or altered, and the
				general condition of the patient during and following surgery.
(II) The full operative report shall be
				written or dictated immediately after surgery and signed or authenticated by
				the surgeon. Where the full operative report is not available to be placed
				immediately in the record, an operative/progress note by the surgeon must be
				entered into the medical record immediately.
5.
Nurse Manager.
A licensed
				registered nurse, who has been appropriately trained in the provision of
				surgical nursing services, shall manage the surgical suite(s) and shall be
				responsible for:
(i) Ensuring that a
				sufficient number of nursing personnel are on duty in the surgical suite to
				meet the needs and safety of the patients;
(ii) Ensuring that surgical technicians
				perform scrub functions only under the supervision of a licensed registered
				nurse who is immediately available to respond to emergencies;
(iii) Delineating the duties of scrub
				personnel and circulating registered nurses in the surgical suite;
(iv) Providing for orientation and on-going
				education and training of surgical personnel providing services within the
				surgical suite, to include at least equipment usage and inspections, infection
				control and safety in the surgical area, cardiopulmonary resuscitation, patient
				rights, and informed consent;
(v)
				Ensuring that patients are monitored and provided with nursing care from the
				time they enter the surgical suite to the time they exit the area;
(vi) Developing criteria for the use of
				equipment and supplies brought into the surgical suite from other areas;
				and
(vii) Ensuring that the
				operating room register is current and complete.