North Dakota Administrative Code › Title 33 - State Department of Health › Article 33-07 - Licensing Medical Hospitals › Chapter 33-07-01.1 - Hospitals › Section 33-07-01.1-29 - Surgical services

Current through Supplement No. 393, July, 2024
1. The general
				acute hospital that provides surgical services shall have effective policies
				and procedures regarding surgical privileges, maintenance of the operating
				rooms, and evaluation of the surgical patient.
a. Surgical services must be provided in a
				manner sufficient to meet the surgical needs of the patients. The surgical
				service must have a defined organization, must be integrated with other
				departments and services of the hospital, and must be governed by current
				written policies and procedures.
b. Surgical services must be directed by a
				physician who is qualified by training and experience and approved by the
				medical staff and governing body.
c. A roster of physicians, specifying the
				surgical privileges of each, must be maintained and available to staff in the
				surgical services area and in the files of the hospital administration.
d. The operating rooms must be
				supervised by a qualified registered nurse.
(1) A licensed practical nurse or a surgical
				technician may be used as "scrub nurse" under the supervision of the registered
				nurse.
(2) A registered nurse may
				perform circulating duties in the operating room in accordance with applicable
				state law. Licensed practical nurses and surgical technicians may assist in
				circulating duties under the supervision of a registered nurse who is
				immediately available to respond to emergencies.
e. The following equipment must be available
				for use in the surgical services area: call-in system, cardiac monitor,
				resuscitator, defibrillator, aspirator, tracheotomy tray, and such other
				instruments or equipment available for lifesaving measures.
f. The surgical services area must be located
				so that traffic in and out can be and is controlled and there is no through
				traffic.
g. All infections of
				clean surgical cases must be recorded and reported to administration and
				medical staff. A written procedure must be established for the investigation of
				such cases.
h. The operating room
				register must be maintained as identified by hospital policy and procedure.
i. There must be a complete
				history and physical examination, including any indicated laboratory and x-ray
				examination reports, in the medical record of every patient prior to surgery,
				except in life-threatening emergencies. If this has been transcribed, but not
				yet recorded in the patient's record, there must be a statement to that effect,
				an admission note identifying any abnormal findings, and the preoperative
				diagnosis in writing by the physician in the patient's medical record.
j. An operative report describing
				techniques, findings, and tissue removed or altered must be dictated or written
				immediately after the surgery and signed by the surgeon.
k. There must be a properly executed informed
				consent form consistent with hospital policies for operation in the patient's
				medical record prior to surgery, except in life-threatening emergencies.
I. If outpatient surgical services
				are offered by a hospital, the quality of the services must be consistent with
				the inpatient surgical services in accordance with the complexity of the
				services.